Location: Burlington,MA, USA
Our Integrated Network brings together a diversity of experienced private practice and employed physicians as well as community and academic providers. While we are one unified network, we focus on different geographic regions, with local care teams convening to ensure healthy, happy neighborhoods throughout the greater Boston region.
We are hiring for individual role in the following covered region:
Monday– Friday 40 Hours flexible during regular business hours
The individual will work from their home but requires in person home visits when applicable.
Job Overview
This positionutilizesthe case management processand works closely with other members of the care team tohelp ensure that patients receive comprehensive and coordinated care through the continuum of care.This position is anintegral member of the care team who conducts comprehensive clinical assessments, develops a patient-centered care plan, and engages the patient through motivational interviewing. The goal is to improve the quality of care and health outcomes for selected at-risk populations and promote the efficient delivery of health care services.Assesses, plans, implements, coordinates, and evaluates the plan of care in partnership with the patient/caregiver and other members of the health care team.
Job Description
Minimum Qualifications:
1. Massachusetts RN Licensure.
2. Obtain appropriate state board where services will be provided as a registered professional nurseORCurrent multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) within three (3) months of hire.
3. Three (3) years of clinical experience in an acute care setting.
4. Valid driver's license in current state of residence.
5. Basic Life Support Certification AHA or certification providing classroom hands on training for Healthcare Providers.
Preferred Qualifications:
1.Bachelor'sdegree
2.Five (5) years of experiencein acute, subacute, or home care, palliativecareand hospice experience a plus
3.Case Management certification and experience.
4.Bilingual
Duties and Responsibilities:Theduties and responsibilities listedbeloware intended to describe the general nature of workandare not intended to be an all-inclusive list.Other dutiesand responsibilitiesmay be assigned.
1.Prepares for patient interaction by gathering information from the patient's medical record, when available, and communicating with the healthcare provider and other clinical team members.
2.Coordinates all aspects of care for patients across the continuum of care.Advocates for patient needs and negotiates for services asrequiredtoprovidecost effective and quality care.
3.Develops trusting, professional, caring relationships with patients and families, engaging respectfully and with an emphasis on service.
4.Acts as lead member of multidisciplinary patient care teams, including collaboration with the healthcare provider and patient/caregivers asappropriate.
5.Performs patient assessments toidentifyand prioritize the patient's medical needs, behavioral health conditions, health system resources and social determinants, while alsoidentifyingpatient's knowledge gaps.
6.Makes home or site visits asrequired.
7.Establishesgoals that are patient specific and identified as part of the patient's self-management goals.
8.Communicates with health care providers on behalf of patients/caregivers as needed and as requested by the patient, including communicating abnormal findings and patient concerns ina timelyand thorough manner.
9.Conducts medication reconciliation and provides education and consults with the pharmacist as needed.
10.Develops patient-centered care plans with the patient/caregiver,providingall information to the healthcare provider, andestablishesappropriate timelinesfor achieving identified goals.
11.Updates the patient care plan as changes in status occur and communicates with the healthcare provider and other members of the treatment team asindicated.
12.Participatesin quality improvement activities to enhance clinical and operational initiatives and programs.
Physical Requirements:
1.Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc.
2.This islargely asedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending / descending stairs andoperateoffice equipment.
3.Frequentlyrequiredto speak, hear,communicateand exchange information.
4.Able to see and readcomputersdisplays, read fine print, and/or normal type size print and distinguish letters,numbersand symbols.
5.Occasionally lift and/or move up to 25 pounds.
Skills&Abilities:
1.Familiarity with the target community andfeelsconnected to that community.
2.Excellent interpersonal, conflict resolution, and communication skills telephonically as well as face-to-face.
3.Demonstrateability to work well with people of various ages, backgrounds, ethnicities, and life experiences.
4.A robust understanding of management of chronic health conditions and population management.
5.Familiarity with Motivational Interviewing.
6.Ability to prioritize and resolve critical issues efficiently and effectively.
7.Detail oriented, with strong organizational skills and multi-tasking abilities.
8.Very strongworking knowledge andproficiencywith technology and business software (Microsoft Office).
9.Experience with Electronic Medical Records andpossessa willingness and ability to learn andutilizenew technologyand procedures that will continue to develop in their role and throughout the organization.
10.Ability to work independently with minimal supervision and as part of a team.
Job ProfileSummary
This role focuses on providing professional and nonprofessional nursing care servicesin accordance withphysician orders.In addition, this role focuses on performing the following Care Manager related duties: Works as part of a multidisciplinary team to coordinate their patient's carein an effort toimprove patient outcomes and create efficiencies.A professional individual contributor role that may direct the work of otherlower levelprofessionals or manage processes and programs.The majority oftime is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typicallyacquiredthrough advanced education.A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience.Typicallyresponsible for: managing projects / processes, working independently with limited supervision,coachingand reviewing the work oflower levelprofessionals, resolving difficult and sometimes complex problems.
Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at...@tuftsmedicine.org.