Job Description

Established in 1980, the Greater Lawrence Family Health Center, Inc. (GLFHC) is a multi-site, mission-driven, non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to a culturally diverse population throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program.

GLFHC is currently seeking a RN, Care Manager to join our Team. The RN Care Manager serves as an integral member of the healthcare team to improve the clinical and operational performance for a subset of assigned patients, namely those with HIV, viral Hepatitis and Substance Use Disorder (SUD). The role will focus on organizing, planning and coordinating the delivery of care as provided by the healthcare team; and providing nurse care services such as follow up visits, medication teaching and monitoring. As a case manager, the RN Care Manager will be responsible for coordinating care for a set number of patients as well as ensuring the care meets standard quality measures. The RN Care Manager will facilitate access to care and retention in care, consistent with Massachusetts Department of Public Health, Boston Public Health Commission established Standards of Care, and the Bureau of Substance Abuse Services.

Clinical Care Activities

• Conducts an intake on all new patients; implements a culturally competent plan of care that will help the client achieve their health goals and evaluates the plan per disease protocol.
• Provides initial and ongoing education on HIV and viral Hepatitis; counseling on harm reduction and adherence support.
• Leads the Comprehensive Care Clinic (HIV) and Viral Hepatitis clinic by preparing a pre-visit document, scheduling patients, managing clinic flow, and coordinating services for the patient. Provides patient care (adherence assessment, education and counseling, immunizations) in these specialty clinics.
• Documents each contact with patient or outside agency in the EMR according to protocol.
• Utilizes ascribed processes for managing the needs of complex patients, initiating interventions based on physician approved patient-specific protocols and order sets.
• Provides direct patient care, if indicated and approved by the manager, which may include immunizations, phlebotomy, and directly observed therapy.
• At the request of the patient, participates in or facilitates partner notification and family education.
• Regularly assess progress toward goals and identifies patients who are not adhering to their medical plan (medical visits, laboratory evaluations, pharmacy pickups) and provides outreach, including home visits, to assess barriers to care, provide education and counseling and assists client in accessing medical care and treatment.
• Remains current on basic principles of HIV and viral Hepatitis.

Coordination of Care Activities:

• Coordinates patient care with other members of the medical team, including PCP, HIV and HCV specialist, medical case manager (CHW), nutritionist, pharmacist, and any other members of the team.
• Coordinates and/or provides outreach efforts to new patients to assist them engage in care.
• Assesses progress toward goals based on clinical judgment and review of trends in clinical data.
• Maintains an up-to-date client list with relevant quality indicators.
• Prepares documentation for HIV and Hepatitis case conference and participates in case discussions.
• Coordinates client care during transitions, such as intakes, discharge, institutionalizations (i.e. correctional facilities), hospitalizations, etc.

Qualifications:

• Massachusetts Registered Nurse License.
• Current BLS certification.
• Minimum of 2 years’ experience in case management or care coordination preferred.
• Knowledge of clinical and cultural issues involved in the care of Latino, African American and gay, lesbian and transgender as well as those with substance abuse.
• Strong clinical and assessment skills.
• Bilingual Spanish/English strongly preferred.
• Outstanding communication skills, self-motivation, organization and flexibility; commitment to improve care in underserved population; collaborative work style; relationship building by meeting directly with patients, families and providers in various settings; high level of accountability; reliable transportation; computer skills.
• Valid Massachusetts Driver’s license and access to reliable transportation.

GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.