Outpatient Registered Nurse Case Manager

The care manager is an integral part of the primary care team and is responsible for ensuring that the primary care provider and practice team maintains a central role in coordinating and managing the care of high risk, high complex vulnerable patients and that the patients receive optimal care including acute illness management, chronic disease management, and preventive care across multiple health settings and multiple physicians/providers.

Integrates the patient/family into care coordination and care management planning and communications and ensuring the patient/family are informed and supported in decision-making; Work with hospital care managers to transition care for patients discharged from the hospital within 24-48 hours to prevent readmission and related complications;

Comprehensively assessing patient’s physical, mental and psychosocial needs; Triaging high risk patients to identify highest risk patients based on severity of disease, self-care limitations, lack of family support, severe socioeconomic factors, poly-pharmacy and health care utilization trends; Collaborating to develop care plans that prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status and minimize hospital and ER utilization.

Current MA RN license.

Must have at least three to five years experience in primary care including administration and program management. Skills include comprehensive nursing assessment, problem identification and care plan development, disease management, screening for developmental issues, depression and other psychological conditions and frailty; behavioral strategies including motivational interviewing and self-management support, relationship building with patients, staff and providers, documentation in an EMR; computer skills including word, excel and PowerPoint.

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Lowell Community Health Center is an Equal Opportunity Employer. We are proud not only of being one of Lowell's largest primary care providers, but of our history serving the community. For over 40 years, Lowell Community Health Center has been offering quality, caring, and culturally appropriate health care services to the people of Greater Lowell, Massachusetts.