RN Case/Care Manager
CenterWell Senior Primary Care
Community Wellness Advocate
Boston Medical Center (BMC)
full-time
Posted on:
Origin: • 🇺🇸 United States • Massachusetts
Visit company websiteJob Level
JuniorMid-Level
About the role
- Initiates face to face contact with eligible patients to describe role, explain participation benefits and begin screening process
- Schedules and completes initial hospital, clinic, or community-based visit screening, care plan, and follow up visits and phone calls
- Teaches key educational messages using culturally, linguistically and educationally appropriate strategies
- Clearly documents all activities in the patient’s record and care management system
- Participates in community outreach, presentations to community organizations, development of materials, and phone calls
- Works with patients and providers to set goals and provides guidance to achieve those goals
- Reinforces educational messages regarding disease self-management by linking clients with supportive community services and programs
- Presents patients at case review meetings and consults with Nurse Care Manager, clinical staff, behavioral health teams and PCP
- Functions within an interdisciplinary team connecting the patient with resources as needed
- Records and monitors participants’ progress toward goals within specific timeframes and documents assessments in Epic system
- Prepares reports and documents as needed or requested
- Assists patients with organizing records, making follow-up appointments, attending appointments, and filling prescriptions
- Helps patients fill out applications for Medical Assistance, Housing, and SNAP
- Provides advocacy, patient education and warm hand offs to community-based and hospital-based programs
- Assists patients in addressing barriers to concrete supports (healthcare, behavioral health, financial assistance, child-care, housing, utilities, food, entitlements, clothing, transportation, violence prevention, social isolation)
- Coordinates with community-based long-term services and supports and may visit patients in hospital and ER to facilitate transitions of care
- Provides intensive home and community-based outreach, motivational interviewing, goal setting, resource connection and accompaniment to medical appointments as needed
- Establishes culturally appropriate and trusting relationships with patients and families
- Participates in training, supervision and program meetings; develops and maintains strong relationships with community resources
- NOTE: The CWA will not provide hands on care or other home health services (performance assessments, provision of care, treatment, counseling, or monitoring of patient’s health status)
Requirements
- HS Diploma with community experiences or Bachelor’s degree
- Driver’s license required
- Must possess a valid driver's license and have vehicle transportation
- Minimum of 2 years prior healthcare, public health, or community-based experience in community setting
- Basic knowledge of healthcare system
- Outstanding interpersonal skills to interact with families and patients
- Interest in community health and outreach
- Exceptional organizational skills; ability to multi-task and work independently and as part of a team
- Demonstrated oral and written English communication skills
- Fluency in Portuguese or Spanish preferable
- Understanding of how language, culture and socioeconomic circumstances affect health
- Desire to work with diverse, multi-cultural and multi-lingual populations
- Proficiency with Microsoft Office applications (MS Word, Excel, Access, Outlook) and web browsers
- Proficiency with data entry and data tracking
- Must complete a background check (Electronic Employment Verification Program / E-Verify)
- BMC requires all staff to be vaccinated against COVID-19 and flu, as well as receive a booster dose of the COVID-19 vaccine
