Primary Care Team Nurse Care Manager

Position Overview

North Shore Community Health (NSCH) is an industry leader in exceptional community healthcare delivery. The Primary Care Team Nurse Care Manager (PC team RN CM) is a registered nurse whose primary responsibility is managing a panel of patients on an assigned primary care team identified for care management. Working collaboratively with the primary care team, specialty NSCH care teams, and community care providers, the PC team RN CM coordinates the overall health care utilization for NSCH’s most vulnerable patients

Care Coordination and Team Collaboration

• Manage referrals and reports for patients identified for care management from sources such as the hospital care transitions report, provider referrals, and risk stratification reports.
• Outreach to, engage with, and manage a panel of patients as outlined in health center care management workflows and ACO guidelines
• Assess and evaluate patient care needs
• Analyze and interpret data and make informed judgments related to patient care
• Create patient-centered care plans in collaboration with the patient, based on individual goals, preferences, resources, and barriers
• Evaluate outcomes of interventions and initiate changes in care plans. Tailor care management to the patient's focus, helping them achieve their set goals whenever possible.
• Document in the patient's medical record and other care management platforms according to standards set by ACO, PCMH, and other regulatory requirements
• Communicate with the patient’s care team members outside the health center as needed, including specialists or visiting nurses, to help coordinate care.
• Serve as a liaison between NSCH and other care management programs and community-based organizations.
• In collaboration with CHWs, ensure patient access to local community resources and help link care teams/patients with the appropriate resources.
• Connect primary care team patients with needed behavioral health services, flexible services, Community Partners, respite care, and other services.
• Guide care team in accessing durable medical equipment, health services, and other community-based social services for patients.
• Provide care coordination, facilitate care transitions, support the completion of referrals, and/or provide and confirm appropriate follow-up with care providers within NSCH and with collaborating community care providers.
• Oversee hospital and emergency department discharge workflows for patients on assigned panels.
• Collaborate with specialty nursing care teams to connect patients with Hep C/HIV care, substance use disorder treatment, chronic disease/diabetes care, and anticoagulation management.

Primary Care Team RN Responsibilities

• Perform job duties of the PC Team RN as needed, which include:
  • Collaborate and communicate with team primary care providers and other care team members to ensure quality and continuity of patient care on the primary care team
    • Participate and coordinate team huddles
    • Manage clinically related phone calls for the team, including but not limited to triage of same-day appointments, abnormal labs, medication questions, and hospital discharges
    • Review refill requests from pharmacy and patients based on medication refill protocol; Reconcile patient medication lists and attach pertinent information necessary for the provider to authorize the refill
    • Complete patient forms to the furthest extent possible, including prior authorization forms, requests for VNA services, etc.
    • Perform nurse visits independently and within the registered nurse scope of practice outlined by the Massachusetts Board of Nursing
    • Performs additional duties to fulfill NSCH’s mission as assigned.
    • Hybrid position with flexibility to work remotely based on needs of the organization
  • Delegate activities to a non-nurse (i.e., medical assistant) within the parameters outlined by the Massachusetts Board of Nursing
    (Five Rights of Delegation)

Documentation, Quality, and Other Duties

• Maintain accurate and timely documentation of all nursing care and patient communication, including phone notes, nursing visit notes, and immunization or medication administration documentation, per NSCH policies and protocols.
• Ensure patient quality and coding gaps are addressed and collaborate with the team to help meet population health/quality goals.
• Adhere to productivity goals around areas such as/not limited to, panel size, patient engagement, and nurse visits.
• Manage the patient panel by ensuring engaged patients receive regular, timely outreach tailored to their individual needs. Graduate patients from care management who have met care management goals or who no longer benefit from care management.
• Assist with documentation/memorialization of NSCH care management program, workflows and resource guides to support current and future care management team members
• Perform additional duties to fulfill NSCH's mission as assigned.