Location: Hybrid, MA

Organization Summary:

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices nationally. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

Job Summary:

As an integral member of the care management team, the Licensed Care Manager will have the opportunity to have 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 make it difficult for them to achieve the self-care required to improve their health and well-being. This position is currently hybrid, but requires flexibility, and may vary from day-to-day to meet members where they are.

The Float Pool Position is hybrid though primarily remote and will cover care management vacancies at C3-affiliated FQHCs and affiliated provider groups.

Responsibilities:

Conducts Comprehensive Clinical Assessments
Assures that medication reconciliation is complete depending on MA state licensure. The RN CM will complete the medication reconciliation and may include a pharmacist and/or primary care Team.
Engages members and caregivers in active care planning with a focus on medical, behavioral, social, member-centered care needs. Coaches and guides member/representative to meet bio/psycho/social care goals.
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
May be required to meet members while they are inpatient to provide education and support about the discharge process and transition the member into care management
Assesses the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support based on the member’s needs and preferences.
Connects members with primary care, behavioral health, HRSN services, respite, and other community based social services as indicated and appropriate.
In collaboration with Community Health Workers, creates and maintains 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.
Participates in the integrated care team meetings and rounds as required
Maintain accurate, timely documentation in electronic systems including health center EHRs
Provides coverage for team members who are out of office
Completes credentialing process per health center assignment
Other duties as assigned

Required Skills:

3-5 years of nursing experience, preferably in case/care management, home health, ambulatory care, community public health, coordinating care across multiple settings and with multiple providers
Demonstrated success in working as part of a multi-disciplinary team, including communicating and working with Providers, Pharmacists, Nurses, Community Health Workers, and other health care teams
Ability to flexibly utilize clinical expertise to solve complex problems
Experience working with patients with chronic medical and behavioral health needs
Must be flexible and adaptable to change
Demonstrate the ability to work independently
Must demonstrate excellent organizational and interpersonal communication skills
Ability to balance more than one health center assignment at any given time
Ability to manage multiple EHRs for clinical documentation

Desired Other Skills:

Bi-lingual preferred
Additional qualities that would be a good fit for our team include; Enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a ‘go with the flow’ mentality
Experience using appropriate technology, such as computers, for work-based communication
Experience and proficiency with Microsoft Office and online record keeping
Experience within the ACOs member population preferred, including Medicare/Medicaid
Experience with Epic preferred
Experience working with Federally Qualified Health Centers is strongly preferred
Experience with anti-racism activities, and/or lived experience with racism, is highly preferred

Qualifications:

Current, active MA Registered Nurse license
Case Management Certification (CCM, ANCC RN-BC) preferred, though not required
A valid driver's license and provision of a working vehicle

** In compliance with Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **

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Licensed Care Manager, Nursing - Float Pool