SCO RN Care Manager

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As one of the largest community health centers in the country, NeighborHealth is proud to serve the greater Boston area with a strong commitment to the health and well-being of our patients and communities.

Whether you're a nurse or physician providing direct care, a manager leading dedicated teams, or part of the essential support staff who keep our operations running smoothly — every role at NeighborHealth is vital. Together, we’re advancing medicine and delivering the best care experience for our patients and community!

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Time Type:

Full time

Department:

Senior Care Options (SCO)

All Locations:

1601 Washington Street

Position Summary:

The Senior Care Options (SCO) nurse case manager acts as a liaison between patients, their families, and health care personnel to ensure efficient, prompt health care and to minimize fragmentation and duplication of services. Nurses work closely with SCO patients and their families to create a care plan with the goal of maintaining independence and safety in the community. Care plans for SCO patients address the medical and psychosocial needs of each patient and are developed in collaboration with other SCO team members to ensure implementation of the most cost-effective plan.

Systematically assess the health status of individuals and groups and record the related health data:

• Navigate the electronic medical record

• Collect data on health/symptoms from a patient.

Analyze and interpret recorded data, and make informed clinical judgments and decisions regarding the specific elements of nursing care mandated by a particular situation:

• Correlate new data and symptoms with the existing medical records

• Determine the appropriate response level within established guidelines.

Plan and implement nursing intervention, , prescribed medical or other therapeutic regiments mandated by the particular situation, scientific principles, recent advancements and current knowledge in the field:

• Collaborate with the patient’s provider regarding the assessment and plan as indicated.  Dispense medications per orders/protocols.

• Report adverse reactions to medication and/or treatments in accordance with policy.

• Performs treatment and interventions as indicated or directed.

Provide and coordinate health teaching required by individuals, families and groups to maintain the optimal possible level of health:

• Educate the patient on test results, new care plans and/or other relevant health care information including the use of newly prescribed medications and/or changes in the current medication regime.

• Evaluate outcomes of nursing interventions, and initiate change as indicated.  Assess and reassess patients as needed.

• Collaborate, communicate and cooperate as appropriate with other health care team members to ensure quality and continuity of care.

• Serve as a patient advocate, within the limits of the law.

• Assess a patient through obtaining patient history and performing appropriate test and observation.

• Demonstrates sound clinical judgement/decision making when triaging sick patients.

• Provides thorough and concise documentation of patient’s histories, assessments, plans and treatments. Enters messages as staff messages or telephone encounters in the computer. Documents nurse visits in Epic.

• Follows protocols for management of patients with chronic/acute conditions and transitions of care.  

• Recognizes the safety needs of the elderly and ensures they receive assistance as needed.

• Responsible and accountable for the orientation, training and mentoring of new employees. Provides input into the development of the orientation plan for new employees.

• Follows established departmental policies and procedures for environmental safety and infection control. Actively participates in EBNHC programs and committees.

• Understands organizational structure of  the department and unit routine and adheres to EBNHC policies

• Responsible for continued professional growth and development and participates in required depart5mental activities and meetings.

• Performs other duties as assigned.

• Interacts with patients in a professional and respectful manner, which reflects the needs and concerns of the individual.  Uses communication devices appropriately.

• Promotes a sense of teamwork, maintains a positive attitude.  Open to new ideas and embraces change.  Provides support and direction to other members of the practice team.  Promotes a culture of acceptance, support and collegiality.  Shares new found knowledge willingly with team.

• Solves problems independently, in teams and seeks consultation as appropriate.

• Accepts constructive feedback and incorporates into plan for professional growth and development.

• Understands and implements CCA guidelines and documents in Commonwealthcare Alliance’s approved record.

• Complete biannual and status change assessments

• Utilizes SCO reassess tool in Epic Completes MDS yearly accurately and on time Uses MDS to change patient status as per CCA guidelines

• Works with entire SCO team to establish the plan of care

• Participates in weekly team meetings. Makes appropriate referrals to community services.

• Evaluates the plan of care and communicates with community agencies which include visiting nurses, Adult Day Health programs and vendors. Also conducts home visits.

• Follows hospitalized and Skilled Nursing Facility patients by working with the facility case manager.

Education

• Graduation from an accredited nursing program

• RN licensure in Massachusetts

• BLS certification

• Bilingual skills preferred

Experience

• At least one year of relevant nursing experience in a community health and/or ambulatory care setting preferred

Skills/Abilities

• Demonstrated ability to communicate effectively verbally and in writing

• Familiarity with Windows operating system preferred

Hourly rate starting at $44.00, and up to $64.00 based on experience

EEO & Accommodation Statement:

NeighborHealth is an equal employment/affirmative action employer. We ensure equal employment opportunities for all, without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic. If you need accommodation for any part of the application process because of a medical condition or disability, please send an e-mail to HRrecruit@NeighborHealth.com or call 617-568-4480 to let us know the nature of your request

Federal Trade Commission Statement:
According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website. We do not ask or require downloads of any applications, or “apps.” Job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment.

E-Verify Program Participation Statement:

NeighborHealth participates in the Electronic Employment Verification Program, E-Verify. As an E-Verify employer, all prospective employees must complete a background check before beginning employment.