Clinical Care Manager in Brockton, Massachusetts at Signature Healthcare

Signature Medical Group is transitioning to the Patient Centered Medical Home (PCMH) model of care. The model promotes primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. The Clinical Care Manager position is an integral member of the PCMH team and focuses on the following goals for identified high risk patient populations: · Managing care via integrated care plans, health goals and continuous assessments · Providing self care resources along with activation interventions and teaching · Coordinating care by optimizing the EMR, leveraging community resources and improving intra and inter team communications · Working as part of a multidisciplinary care team to provide patient-centered care and to lower total medical expense of high risk/high cost patients The Clinical Care Manager manages a caseload of approximately 75 high risk/ complex patients; of which 20-30 patients are actively followed. This individual provides targeted clinical/non-clinical interventions with the goal of avoiding hospitalization, emergency room visits and out of network specialty care, while improving health outcomes and lowering total medical expense. This individual helps to coordinate care across multiple clinical and non clinical settings and helps patient/families understand their health care options. The Clinical Care Manager also performs home visits as needed. Graduate of an NLN-accredited School of Nursing; Bachelors' of Science in nursing preferred or higher in clinical field. Current RN license in the Commonwealth of Massachusetts. Case Management certification preferred. Valid driver's License. Bicultural preferred (Spanish, Haitian Creole, Portuguese). Minimum of 3 years of broad clinical experience across a variety of settings including ambulatory and/or community health nursing care management/case management/ chronic disease management preferred. Experience with substance abuse and behavioral health conditions preferred. Completion of self-management support training preferred.