RN Care Manager, Hybrid/Remote

5 days ago Be among the first 25 applicants Who We Are Since 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 10,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Our clinicians, case managers, and behavioral health professionals work in more than 30 locations to serve some of our community’s most vulnerable—and most resilient—citizens. From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all. We provide community‑based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face. Job Summary ***NOW OFFERING A $4,000 SIGN ON BONUS*** Hours Full‑time, Monday‑Friday; 8:30 am‑5:00 pm; hybrid model of on‑site and remote work. Union No Patient Facing Yes Position We are looking to hire a dedicated and passionate Nurse Care Manager for our Behavioral Health Community Partners program. This is an outreach position, enabling you to truly meet the patients where they are at, and requires a population‑health lens to provide both preventative and reactionary services. In this role, you will be an autonomous driver of patient wellness by creating and enacting person‑centered care plans for a set patient panel in partnership with Care Coordinators and the patients themselves. You will collaborate with the broader interdisciplinary care team—including Primary Care Providers, BH clinicians, and others—to ensure enrollees receive needed services, have access to necessary resources, and achieve progress toward their care plan goals. Responsibilities Enact essential duties through a mix of onsite and remote days a week. Provide clinical assistance to 3–5 Care Coordinators with panels of approximately 50 patients each, plus a small panel independently managed of approximately 5 clients; this includes chronic disease management and medication support. Engage vulnerable populations as part of a multidisciplinary outreach team, including home visits and outreach to hospitals, homeless shelters, and other settings as needed. Perform timely follow‑up and medication support following transitions of care. Connect enrollees to various needed supportive services and resources. Provide clinical oversight and tracking for annual comprehensive health assessments. Participate in developing patient‑centered care plans and reviewing health assessments for the BH CP enrollees on the panel. Coordinate hospital admission/discharge plans with the behavioral health clinician, PCP, ACO, MCO, etc. Use data to evaluate outcomes of targeted interventions for the panel and assist in adjusting care plans based on this data. Implement prevention & engagement strategies in collaboration with the Care Coordinator. Provide health coaching for groups of enrollees or individual enrollees as needed. Support connection to substance‑use treatment and affiliated services when appropriate. Engage in quality improvement efforts, as led by the BH CP Clinical Team Coordinator and Clinical Program Manager. Qualifications Licensed as a Registered Nurse in the Commonwealth of Massachusetts. Preferred: nursing experience with complex patients; BSN preferred but not required. Experience working with vulnerable populations, including those with a history of trauma, socioeconomic stress, homelessness, or substance use disorders. Experience working on cross‑disciplinary, integrated teams; strong interpersonal skills and clinical problem‑solving. Comfort with autonomous clinical and outreach settings; capable of working with data to track and measure performance. Bilingual skills in Spanish and English strongly preferred. Computer skills: proficient with Microsoft Excel spreadsheets, entering narrative and other data into a database, Epic EHR. Flexibility and strong multitasking skills. Compensation and Benefits The compensation ranges from $40.00 to $58.00 per hour and increases based on years of experience. BHCHP full‑time employees are eligible for a competitive time‑off program, health, dental and vision insurance, 403(b) retirement savings plan, pre‑tax MBTA pass program with 40% discount, additional compensation for demonstrated bilingual proficiency and more. Benefits are prorated for part‑time employees. As an equal opportunity employer, Boston Health Care for the Homeless Program is committed to providing employment opportunities to all qualified individuals and does not discriminate on the basis of race, color, ethnicity, religion, sex, gender, gender identity and expression, sexual orientation, national origin, disability, age, marital status, veteran status, pregnancy, parental status, genetic information or characteristics, or any other basis prohibited by applicable law. Covid‑19 Vaccination: Proof of Covid‑19 vaccination(s) is optional for employment. Candidates who are offered employment will be given details about how to demonstrate receipt of vaccination if they choose to. Please Note: Employment at Boston Health Care for the Homeless is at‑will. Boston Health Care for the Homeless does not sponsor work authorization visas. #J-18808-Ljbffr