The care manager is an integral part of the primary care team and is responsible for ensuring that the primary care provider and practice team maintains a central role in coordinating and managing the care of high risk, high complex vulnerable patients and that the patients receive optimal care including acute illness management, chronic disease management, and preventive care across multiple health settings and multiple physicians/providers.
Integrates the patient/family into care coordination and care management planning and communications and ensuring the patient/family are informed and supported in decision-making; Work with hospital care managers to transition care for patients discharged from the hospital within 24-48 hours to prevent readmission and related complications;
Comprehensively assessing patient’s physical, mental and psychosocial needs; Triaging high risk patients to identify highest risk patients based on severity of disease, self-care limitations, lack of family support, severe socioeconomic factors, poly-pharmacy and health care utilization trends; Collaborating to develop care plans that prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status and minimize hospital and ER utilization.
Current MA RN license.
Must have at least three to five years experience in primary care including administration and program management. Skills include comprehensive nursing assessment, problem identification and care plan development, disease management, screening for developmental issues, depression and other psychological conditions and frailty; behavioral strategies including motivational interviewing and self-management support, relationship building with patients, staff and providers, documentation in an EMR; computer skills including word, excel and PowerPoint.
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Lowell Community Health Center is an Equal Opportunity Employer. We are proud not only of being one of Lowell's largest primary care providers, but of our history serving the community. For over 40 years, Lowell Community Health Center has been offering quality, caring, and culturally appropriate health care services to the people of Greater Lowell, Massachusetts.
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Open job postingAbout the company
Based in the heart of downtown Lowell, Lowell Community Health Center is currently seeking a Full-Time Registered Nurses in the following clinical areas: ADULT, PEDIATRICS and FAMILY MEDICINE. Apply Here to submit a general application: https://www.vscyberhosting2.com/lowell/ With over 400 employees, the Health Center has expanded and relocated to a new state-of-the-art facility as of December 2012. The Health Center is a diverse, community-based health care organization. Lowell Community Health Center programs have been recognized as national models. The Health Center was also named one of the top five health centers in the nation for excellence in cultural competency. The Health Center's employees speak 28 different languages and over 80 staff are trained in medical interpreting. Patients trust Lowell Community Health Center. Every year, we touch the lives of nearly 50,000 people – or almost half the population of the City of Lowell. More than 90% of Lowell CHC patients are low income, and 46% are best served in a language other than English. Since opening our new comprehensive facility in a renovated mill on Jackson Street in 2012, more than 9,000 additional patients have turned to Lowell CHC for a full range of primary care, including OB-GYN and behavioral health services for adults and children, with over 176,000 visits in 2014. We also have a Pharmacy serving health center patients and others in the community