ESSENTIAL FUNCTIONS:

1. Use case management processes to assure quality care is delivered to the practice’s patients, the patient’s families, and the patient’s caregivers in the most efficient and effective manner across the healthcare continuum.
2. Engage patients, patient’s families and their caregivers in understanding, setting, and monitoring patient self-management care plans in a manner that is culturally and linguistically appropriate to the patient and caregiver.
3. Complete health risk assessments as a foundation for developing individualized care plans and outcome goals for patients and their families.
4. Coordinate the patient’s care by facilitating patient, family or other care giver access to Medical Home/Behavioral Health providers, Staff and resources as needed by the patient.
5. Develop and maintain relationships among patients, patient’s families, and the patient’s care team that support patient’s access to the Medical Home.
6. Act as the primary contact point, advocate and source of information for patients and the community partners who help treat them
7. Research, find, and link patients to resources, services and support mechanisms for their care plans and self care management needs.
8. Provide timely communication with patients, make inquiries, execute follow-up actions and help to integrate information into the care plan.
9. Assist the care team in performance evaluation and quality improvement.
10. Participate in continuing professional growth through attendance at workshops and Professional in-services and through individual research and reading, to include communication skills.
11. Demonstrate flexibility, enthusiasm, and willingness to cooperate while working with others in multidisciplinary teams with activities to include participating in daily huddles

REQUIRED KNOWLEDGE & SKILLS:

1. Ability to apply critical thinking skills and make sound judgments both while performing daily responsibilities and throughout the patient’s continuum of care.
2. Knowledge of the Case Management process and the Patient Centered Medical Home (PCMH)
3. Effective oral and written communication skills.
4. Excellent interpersonal skills reflecting clarity and diplomacy and the ability to communicate effectively with all levels of staff and management.
5. Detail orientated, thorough, and able to handle multiple tasks and projects with varying deadlines and priorities.
6. Ability to work with a registry and an Electronic Health record.

REQUIRED EDUCATION & OTHER CREDENTIALS:

1. Registered Nurse with current Massachusetts license
2. Bachelor’s level preparation as a Nurse or the equivalent with appropriate experience in Healthcare.
3. Three to five year experience in a Primary Care practice.
4. Demonstrated skills in Leadership, Advocacy, Communication, Education, and Counseling
5. Culturally effective capabilities demonstrating a sensitivity and responsiveness to varying characteristics and beliefs
6. Bilingual Preferred (Spanish & English).