Hybrid Registered Nurse (RN) Clinical Care Manager - Cambridge to Malden

Job description

Job Summary: The Clinical Care Manager-Massachusetts is a community based registered nurse responsible for providing monitoring, follow-up and clinical care management to dually-eligible enrollees with complex medical, behavioral and social care needs. This position focuses on integrating health services and community resources to coordinate enrollee care for improve health outcomes and enhanced quality of life. Essential Functions: - Engage with the enrollee in their homes and other community settings to establish an effective, complex care management relationship, while considering the cultural and linguistic needs of each member. - Function as a liaison between healthcare providers, community resources, and enrollees to ensure seamless communication and care transitions. - Perform required assessments on a timely basis, including but not limited to Comprehensive Assessment, MDS-HC (or successor) Functional Assessments, and Crisis and Risk Assessments - Engage enrollees in care plan development and implementation, providing routine updates as the enrollee’s status changes - Lead the interdisciplinary care team (ICT) and collaborate with peers both internal and external to the org...