Nurse Care Manager, BH-CP

Who We Are:

Since 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 10,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Our clinicians, case managers, and behavioral health professionals work in more than 30 locations to serve some of our community’s most vulnerable—and most resilient—citizens.

From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all. We provide community-based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face.

Bilingual, Bicultural, LGBTQIA identifying, Black, Indigenous, and People of Color are encouraged to apply.

To learn more about working at BHCHP, watch our video Please Click Here.

Job Summary:

• **NOW OFFERING A $4,000 SIGN ON BONUS***

The Behavioral Health Community Partners program is a new initiative that provides eligible MassHealth enrollees with support to better manage their complex medical and mental illnesses and substance misuse. This particular program has a special patient population focus on individuals lacking stable housing. In this role, you will be working closely with 4 care coordinators employed by several homeless service organizations that have partnered with us on this endeavor including Pine Street Inn, Saint Francis House, and New England Center and Home for Veterans enacting person-centered care for a set patient panel in direct partnership the Care Coordinators and the patients themselves. This is an outreach position, enabling you to truly meet the patient where they are at, and requires the employment of a population health lens to provide both preventative and reactionary services. As a Nurse Care Manager, you will use clinical expertise to collaborate with the broader interdisciplinary care team (PCP, BH clinicians, etc.) to ensure that the enrollees are receiving needed services, have adequate access to necessary knowledge and resources, and are measuring progress towards the goals outlined in their patient-centered care plan.

This is an excellent position for those wanting to address social determinants of health and systemic inequities at both micro and mezzo levels in conjunction with key stakeholders throughout the city.

Hours: Full-time, Monday-Friday; 8:30am-5:00pm; Hybrid model of on-site and remote work

Responsibilities:

• Enact essential duties through a mix of onsite and remote days.
• Provide clinical assistance to 3-5 Care Coordinators with panels of approximately 45 clients each. This includes chronic disease management and medication support.
• Monthly contact (at a minimum) with an identified panel of clients requiring clinical care management.
• Collaboratively work with integrated care team members, including physicians, care coordinators and team coordinators, to ensure enrollees’ needs are addressed and any treatment barriers reduced.
• Engage vulnerable populations as part of a multidisciplinary outreach team. This includes home visits, outreach to hospitals, homeless shelters, and other settings, as needed.
• Perform timely follow up and medication support and education following transitions of care.
• Connect enrollee to various needed supportive services and resources.
• Provide clinical oversight and tracking for annual comprehensive health assessments.
• Participate in developing patient-centered care plans for the enrollees on their panel.
• Work with BHCHP staff at Boston-area hospitals to coordinate hospital admission/discharge plans with the behavioral health clinician, PCP, ACO, MCO etc.
• Use data to evaluate outcomes of targeted interventions for panel. Assist in developing appropriate adjustments to care plans based on this data.
• Implement prevention & engagement strategies in collusion with Care Coordinator and Team Coordinator.
• Provide health coaching for groups of enrollees or individual enrollees as needed.
• Support connection to substance use treatment and affiliated services when appropriate.
• Engage in quality improvement efforts, as led by the BH CP Team Coordinator and Clinical Program Manager.

Qualifications:

• Licensed as Registered Nurse in the Commonwealth of Massachusetts.
• Nursing experience with complex patients preferred.
• BSN preferred but not required.
• Experience working with vulnerable populations, including persons with a history of trauma, those experiencing socioeconomic stress, homelessness, or substance use disorders.
• Experience working on cross-disciplinary, integrated teams.
• Strong interpersonal skills and clinical problem solving.
• Comfort with working in an autonomous clinical and outreach setting.
• Capability working with data to track and measure performance.
• Bilingual skills in Spanish and English strongly preferred (equitable compensation for demonstrated fluency).
• Computer skills: Proficient with Microsoft Excel Spreadsheets, entering narrative and other data into a database, Epic HER.
• Flexibility and strong multitasking skills.