<p>Position Title: Registered Nurse Care Manager (C3) / Public Health Nurse</p> <p>Department: Nursing</p> <p>Supervisor: Director of Nursing</p> <p>Status/Hours Per Week: Non-exempt / 40 hours</p> <p>Primary Function/Position Summary:</p> <p>As an integral member of the care management team, the C3 Registered Nurse (RN) Care Manager/Public Health Nurse working at Upham's Community Care will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic conditions, many of whom also face multiple barriers in their lives which makes it difficult for them to achieve the self-care required to improve their health and well-being. This position requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in person in a variety of potential settings such as but not limited to, the health center, community, home or an inpatient facility.</p> <p>Community Care Cooperative (C3) is a 501(c)(3) not-for-profit, Accountable Care Organization (ACO) governed by FQHCs. Our mission is to leverage the collective strengths of Federally Qualified Health Centers (FQHCs) to improve the health and wellness of the people we serve.</p> <p>Duties & Responsibilities:</p> <ul> <li>Conduct comprehensive assessments and intakes, including but not limited to medical history, history of HIV disease, other medical conditions and client's presenting request. </li><li>Assure that medication reconciliation is complete. This may include a pharmacist and/or primary care team. </li><li>Triage telephone questions and requests from clients. </li><li>Engage members and care givers in active care planning with focus on medical, behavioral, social, member-centered care needs; and coach, educate, and guide members/clients to meet bio/psycho/social goals. </li><li>Provide care coordination, which may include but is not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up. </li><li>May be required to meet members on an in-patient basis to provide education and support about the discharge process and transition members into care management. </li><li>Provide ongoing nurse case management to clients and travel throughout assigned area to engage members at their homes or other locations where the member may be located (in compliance with COVID infection control practices). </li><li>Assess the member's knowledge of their medical, behavioral health and/or social conditions; and provide education and self-management support including symptom response plans based on the member's needs and preferences. </li><li>Work with the PCMH team to link to the RW program for patients who test HIV positive. </li><li>Connect members with primary care, behavioral health, flexible services, Community Partner, respite, and other community based social services as indicated and appropriate. </li><li>In collaboration with Community Health Workers, create and maintain a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services. </li><li>Work with HIV staff to ensure all HIV clients are linked to medical care and are supported to follow through with care. </li><li>Participate in the integrated care team meetings and rounds as required. </li><li>Attend external conferences and training to stay abreast of HIV medical/nursing issues. </li><li>Participate in network and support groups. </li><li>Maintain accurate, timely documentation in electronic systems including health center EHRs. </li><li>Provide coverage for team members who are out of office. </li><li>Handle other duties as assigned. </li></ul> <p>Qualifications</p> <p>Minimum Basic Knowledge:</p> <ul> <li>Associate's degree in Nursing, B.S.N preferred. </li><li>Current, active MA Registered Nurse license. </li></ul> <p>Experience & Qualifications:</p> <ul> <li>3-5 years of nursing experience, preferably in-home health, ambulatory care, community public health, case management, coordinating care across multiple settings and with multiple providers. </li><li>Experience working with Federally Qualified Health Centers is strongly preferred. </li><li>Experience working with a Medicaid population is strongly preferred. </li><li>Case Management Certification (CCM, ANCC RN-BC) preferred. </li><li>A valid driver's license and provision of a working vehicle. </li></ul> <p>Independent Action:</p> <p>Functions independently within scope of nursing practice and health center policies and goals. Refer specific problems to supervisor when clarification of operating policies or procedures is required.</p> <p>Supervisory Responsibility:</p> <p>None</p> <p>Define Access Level to PHI: Level 4: Authorized to access full health information. UCC position and job responsibilities involve the provision of patient care and working as a clinical team member. Staff in this category level, although allowed full access, should only access the necessary information for each respective treatment encounter/circumstance.</p>