Chronic Care Manager - Charles River Community Health

Chronic Care Manager

CLASSIFICATION/STATUS: Exempt, un-licensed, Full Time

IMMEDIATE SUPERVISORY: Chronic Care RN Manager

SUPERVISORY RESPONSIBILITIES: None

FLEXIBLE WORK: Hybrid schedule option

PAY RANGE: Band C $51,000-$65,500/year

WHO YOU ARE:

YOUR ROLE & IMPACT

The mission of Charles River Community Health (CRCH) is to partner with individuals and families so they can thrive and lead healthier lives by delivering the comprehensive, integrated, and equitable primary healthcare that matters most to them. As an integral member of the care management team at Charles River Community Health (CRCH), the Care Manager will have the opportunity to make 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 requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in person in a variety of potential settings such as but not limited to, the health center, community, home, or an inpatient facility.

YOUR RESPONSIBILITIES

The Care Manager works with the Chronic Care Management (CCM) team, primary care providers, pharmacists, BH, CHWs and nursing to identify and engage patients in care management with a focus on patient experience, improving health, and reducing cost. The individual is responsible for working with patients to identify strengths and barriers to encourage and support the progress in achieving the goals outlined in the individualized, patient-centered care plans in conjunction with the multidisciplinary team. Excellent interpersonal skills, knowledgeable about chronic conditions prevalent in the CRCH population (Substance Use Disorder, Serious Mental Illness, Congestive Heart Failure, COVID, diabetes and any chronic disease), patient engagement skills, and the ability to work independently and collaboratively are key requirements of the job. The Care Manager will proactively seek out opportunities to care for patients, including during primary care visits, during ED or IP visits, out in the community, or on the phone.

The Care Manager will proactively seek out opportunities to care for patients, including during primary care visits, during ED or IP visits, out in the community, or on the phone.

• Identify and assist recruitment of appropriate patients for care management from lists and referrals, in collaboration with Chronic Care RNs (CCRN), primary care providers, and rest of CCM team.
• Meet the patient where he/she is; observe the patient without intervention or judgment.
• Has knowledge of common chronic medical conditions presented in the population served and is able to:
• Coordinate appointments for patients
• Education patient on referral process within CRCH and at outside hospitals
• Connection with appropriate community and state resources as needed, such as transportation assistance, translation services, etc.
• Collaborate with patients’ families, friends, and social supports in care of patient
• Communicate well with CCRNs and Chronic Care Nurse Manager and escalate any concerns of patient safety as necessary
• Maintain accurate, timely documentation of case management activities in EHR, and internal documentation
• Assist with information gathering on medication compliance with team
• Engage members and caregivers in active care planning with a focus on medical, behavioral, social, member-centered care needs. Coach and guide member/representative to meet bio/psycho/social 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.
• Conducting regular follow-ups with patients to evaluate progress, promote continuity of care, and ensure improved health outcomes.
• Delegate assignments to Community Health Workers and/or Patient Navigators or Social Workers, follow up on completion, and be consistently available for timely consult regarding patient matters during business hours.
• Participate in local site operations, including team meetings and integrated care team meetings and rounds as required.
• Understand the relationship between work done in the ACO's system and the work done in EHR. Ensure that workflows are optimized to recognize and support both the ACO's system and EHR.
• Facilitate interdisciplinary consultation on patient's behalf through participation in rounds, team meetings, and clinical reviews.
• Establish and comply with quality metrics for performance and adhere to documentation and work flow standards.
• Maintain HIPAA standards and confidentiality of protected health information.
• Adhere to departmental/organizational policies and procedures.
• Provide coverage for team members who are out of office.
• Ensure that all care management is offered in a culturally and linguistically-appropriate manner and with disability competence.
• Ensure that all needed accommodations are consistently made for members with disabilities.
• Promote a sense of "team work” through demonstration of self-direction and self-motivation. Solve problems independently or know when to seek consultation.
• Work closely with the CCRNs and Chronic Care Nurse Manager to assist with the running of the CCM.
• Perform other duties as assigned by the Chronic Care Nurse Manager, or designee.

YOUR QUALIFICATIONS, COMPETENCIES, TRAITS

• Bachelor of Science Degree required in social sciences, social work, or other health related field.
• Experience working in a healthcare setting with experience in outpatient medical setting, or other related outpatient practice, preferred
• Case management, care management, or other patient care coordination experience preferred.
• Experience with Epic, preferred
• Familiarity with MassHealth insurances and ACO, preferred
• Must have demonstrated and solid interpersonal, communication, and organizational skills.
• Must be able to communicate effectively with a multidisciplinary team
• Must have knowledge of Ambulatory and clinical practices, workflows, and operations.
• Must work well independently, have sound decision making skills, and work effectively with and through inter-professional colleagues when required to make and facilitate complex decisions.
• Experience working with historically underserved populations preferred.
• Bilingual/bicultural preferred.
• Must have a willingness to work flexible hours to meet the organization's needs/demands.
• Must be able to travel to either Charles River Community Health site (Brighton and Waltham) as needed.
• Must have excellent communication skills, particularly with people from diverse cultures whose primary language is not English, with the ability to understand the community, population, and patients we serve.
• Must have experience in diverse cultures, with strong commitment to promoting Diversity, Equity, and Inclusion and reducing inequities.
• Must believe in the work we do at CRCH, with a strong passion to serve underserved populations in diverse settings.

WHO WE ARE & WHAT WE DO

Charles River Community Health’s mission is to partner with individuals and families so they can thrive and lead healthier lives by delivering the comprehensive, integrated, and equitable primary healthcare that matters most to them.

CRCH is a comprehensive practice providing medical, pharmacy, dental, behavioral health, optical, and vision services to diverse underserved local communities. We serve over 13,500 patients annually, and 90% of those served are low income, while over 70% need services in a language other than English.

We are committed to providing patients with timely access to the right care, at the right place and at the right time, collaborating with other organizations to connect patients with a comprehensive range of services and provide continuity of care, and creating new community partnerships to meet the changing needs of patients and the community.

We value caring for everyone with dignity, respect, and compassion, reducing cultural, financial and other barriers to care, and eliminating health care disparities for our patients. We also advocate for the needs of our patients, the community, and public health causes.

OUR PROMISE

If you are passionate about providing service excellence in a mission-driven, team-oriented, and progressive organization, you will find your career as the Chronic Care Manager rewarding and impactful! You will be part of a dynamic and fast-paced team with a shared vision to break down barriers in delivering healthcare excellence!

OUR BENEFITS & PERKS

Medical & Dental Insurance

Short & Long-term Disability Insurance

Generous Paid Time Off

Flexible Spending Account

Employee Assistance Program

Tickets at Work

Health Reimbursement Arrangement

Travel Reimbursement

Professional Development Opportunities

Solid track record of developing and promoting employees internally!

Charles River Community Health is strongly committed to diversity and a workplace environment that respects, appreciates and values employee differences and similarities. By providing and supporting a work culture that fosters and builds upon diversity and its strengths, CRCH will better serve our local communities and continue to provide quality patient care and services. CRCH is an employment at-will organization and an equal opportunity employer committed to maintaining a work and learning environment free from discrimination on the basis of sex, race, color, religion, national origin, pregnancy, gender identity, sexual orientation, marital/civil union status, ancestry, place of birth, age, citizenship status, veteran status, political affiliation, genetic information or disability, as defined and required by state and federal laws. Additionally, CRCH prohibits retaliation against an applicant or employee because he or she has engaged in protected activity under the statutes prohibiting discrimination in the workplace.