RN Case Manager – Chronic Disease

About Us

We’re more than just quality treatment for substance use disorders. We’re a total health community. At SSTAR, our mission is healing the community, one person at a time. We will provide a personal level of healthcare and addiction treatment that addresses the mental, physical, and spiritual well-being of everyone we touch. SSTAR is a Federally Qualified Health Center (FQHC) which affords our employees eligibility to apply for one of our three Loan Repayment Programs.

The RN Case Manager is responsible for managing high risk, chronic illness patients to promote effective education, self-management support and timely healthcare delivery to achieve optimal quality outcomes. The RN Case Manager acts as an advocate for the individual’s healthcare needs, and coordinates care to minimize the fragmentation of health care delivery systems.

Compensation: $41.37 - $44.56/hour

Schedule: Monday - Friday 8am to 4pm

Benefits

• 403B
• Dental insurance
• Disability insurance through Massachusetts PFML
• Employee discounts, cell phone, eyewear etc.
• Health insurance
• Life insurance
• Paid time off
• Vision insurance
• Flexible Spending Account
• Opportunities to earn CEU's
• Voluntary Benefits including but not limited to, Disability, Life, Critical Illness, Accident and Disability Insurances

Duties & Responsibilities

• Work closely with health care team to establish Treatment and Educational Plan for patients with asthma/COPD, nicotine dependence, diabetes, hypertension, and other chronic diseases that is documented and implemented in the medical record.
• Nursing visits and education sessions with patients reviewing diagnosis, compliance of medical care and recommendations documented and implemented in the medical record.
• Track appointments, referrals, tests, and labs as determined by Standards of Care, for patients identified at high risk due to their illness.
• Work closely with navigators to refer patients to community partners, complex case management, and other community resources as needed or requested by providers.
• Track durable medical equipment requests and complete forms and referral to supply companies to ensure patients receive needed devices in a timely manner as well as educate patients how to use these devices, as necessary.
• Work with the RN Case Management team to supervise emergency department/hospital discharges to ensure follow ups with RN or provider are scheduled and fulfilled appropriately based on medical need.
• Liaison between medical providers and patients - Refill prescriptions per nursing standing order or task providers for refills and other concerns as appropriate. Utilize patient portal wherever possible and support patient usage.
• Maintain accurate patient records and patient confidentiality.
• Engage in professional development activities to keep abreast of case management practices and patient engagement strategies.
• Attend TQM meetings and support and assist QI RNs as needed with disease prevention and health promotion per quality measures.
• Perform spirometry testing with patients to determine pulmonary function and make recommendations for medications and referrals as appropriate.

• Adheres to the work schedule. Obtains supervisor approval in advance of schedule conflicts as well as late arrivals or early departures.
• Records all hours worked by the last day of the pay period.
• Responds appropriately to all Code Calls
• Follows the incident reporting policy and procedure in reporting any unsafe/unusual safety issues.
• Treats patients, and colleagues with dignity and respect; honors each persons right to privacy/ maintains very strict patient and colleague confidentiality.
• Timely completes all trainings, certifications, re-credentialing and licensing renewals requirements.
• Maintains current awareness of SSTAR’s communications by checking, reviewing and responding to work emails at minimum on a weekly basis. Asks for assistance when needing help or to fully understand the email message.
• Other duties as required.

Education & Experience

• EDUCATION: Associates degree in nursing AND; BA preferred

  WORK EXPERIENCE: 2 years’ experience with direct nursing care or community setting

  LICENSING: Current Registered Nurse Licensure

  CERTIFICATION(S): CPR

  KNOWLEDGE:

  • Strong knowledge of clinical assessment skills and experience with chronic disease management
  • Experience working with an electronic medical record
  • Proficiency in medication indications and side effects.
  • Understanding of medical tests and requirements for test as to provide the patient with appropriate information/education.
  • Use of the Columbia Suicide Assessment tool; able to assess based on scoring results

  SKILLS & ABILITIES:

  • Ability to work collaboratively with people of divers cultures and lifestyles
  • Ability to communicate effectively with providers, medical staff and support staff
  • Excellent organizational skills and ability to handle multiple priorities while remaining calm and professional.
  • Ability to be self-motivating and work independently
  • Problem solving skills.