Clinical Care Manager

Pay : $90,000.00 per year

Schedule : Monday-Friday 9am-5pm

Location : Somerville, MA

Job description :

The Clinical Care Manager - Registered Nurse (RN) on the Community Partner team provides clinical care management and intensive care coordination for people with complex medical and behavioral health needs. The RN will act as a Clinical Care Manager and is a vital member of the Community Partner Care Team which includes licensed behavioral health clinicians, a care transitions manager, community health workers and a team administrator. The RN is supervised by the Care Team Leader and will learn about working on a community-based interdisciplinary team, trauma / recovery skills, care transitions support, behavioral health and substance use disorder services, and person-centered care planning. The RN must be willing to visit enrollees in their homes throughout the service area as well as work from our office.

The Clinical Care Manager - Registered Nurse will also :

• Conduct comprehensive assessment of enrollees including the medical, psychiatric and social components.
• Review / sign off on medical component of comprehensive assessment
• Monitor enrollee's health status and needs and provide nursing and medical care coordination, including revising health related treatment goals and plans in collaboration with the enrollee and the Care Team.
• Coordinate the development, implementation, and ongoing review of the care plan.
• Conduct medication reviews and reconciliation including adjustment by protocol.
• Communicate and collaborate with ACO teams and serve as a team resource.
• Follow up of an enrollee's inpatient stay, (including hospital, shelter, substance abuse programs, SNF), and collaborate with enrollee, Care Team, and hospital staff to coordinate transitions of care.
• Collaborate and communicate with the enrollee's other medical, behavioral health and home-based providers regarding changes in services, hospitalizations, and other care needs and goals
• Obtain required Prior Authorization from Managed Care Plan (ACOs, MCOs) for relevant and necessary services.
• Perform other related duties, as assigned.

Requirements / Preferences :

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