Care Coordination Nurse Manager

• Commitment to patient- and family-centered care. 
• Accountability to support each other in providing excellent care and outcomes.
• Realizing professional practice as an engaged and thriving staff.
• Excellence in nursing practice through our commitment to performance improvement, evidence-based practice, and research.

• Upon referral of patients, reviews medical and psychosocial history, assesses problems and refers patients as appropriate in a timely, courteous manner
• Provides case management services to medical department patients as indicated
• Provides information to patients about available community resources and assists patients to determine eligibility and obtain services by giving resource list and/or contacting services directly
• Provides on-going supportive maintenance to patients as appropriate and conducts outreach to encourage clients to utilize further needed services

• Oversees the clinical and administrative supervision of the Care Coordination staff
• Supervises the Nurse Care Coordinators and Community Health Workers
• Provides program coverage and assists front line staff with task completion as needed
• Ensures that newly hires receive a comprehensive orientation program
• Plans and manages safe clinical care services and operations and adheres to core expectations of the Patient Centered Medical Home (PCMH).
• In collaboration with the Executive Director of Nursing makes employment-related decisions regarding assigned staff within the scope of defined authority and following established agency and program guidelines 
• Supports and continually improves the provision of professional, comprehensive, and effective clinical services for all Fenway Health patients

• Maintains proficiency in clinical areas and serves as a resource and role model for nursing personnel and students. 
• Attend clinical and administrative meetings; participate in committee functions; and participate in activities and committees within the scope of position or as directed.
• Assists in administering organizational and departmental policies and procedures in collaboration with other departments and in accordance with state, federal, and organizational guidelines; participates in reviews, revision, and communication to ensure adherence.
• Demonstrates the ability to work independently and as an effective leadership team member.
• Assists in developing nursing goals and objectives, planning, and implementing measurable and sustainable activities consistent with the Fenway Health Strategic Plan.
• Facilitates operational activities related to enhancing clinic efficiencies, patient engagement, and cost-effective outcomes for clinical services.
• Monitors budget to ensure the delivery of quality patient care in a cost-effective manner. 
• Facilitates plans to implement and monitor clinical and operational quality and performance improvement and regulatory readiness.
• Investigates and responds to patient complaints and incident reports relating to clinical care and processes and implements corrective action and preventative measures as applicable.
• Oversees selection, onboarding, performance evaluations, and performance improvement and disciplinary process for clinical staff in collaboration with Human Resources.
• Oversees and promotes employee professional development and adherence to workflows, scope of practice, policies and regulatory requirements.
• Acts as liaison as necessary between individual parties (e.g. patients, providers, employees) and other departments to promote and facilitate communication, problem solving, crisis intervention, resource utilization, and conflict management.
• In collaboration with other staff, manages grant funding reporting and compliance oversight
• Assists the Executive Director of Nursing with program development and practice innovation initiatives
• Assists the Fenway health Quality Team in the oversight of the quality and effectiveness of the integrated behavioral health services and care coordination
• Demonstrates initiative and commitment to continuously improve services and processes the positively impact patient care and organizational goals.

• Coordinates and monitors caseloads of Ryan White grant funded case managers
• Connects with referral sources and internal points of entry to ensure eligible patients are enrolled in the Ryan White case management program
• Assigns cases for assessment and service planning
• Monitors caseload reports to ensure timely documentation of assessments, service plans and obtaining required signatures
• Supports case managers by designing processes that improve intake and discharge rates and compliance with funder expectations
• Assist to develop and implement quality assurance projects related to community-based case management work to ensure proper documentation, appropriate utilization of transportation services and that the service is appropriate for each patient’s service plan
• Assist case managers with ensuring that community-based case management services are offered to patients with the most need

• Under the direction of the Executive Director of Nursing, and in collaboration with medical department leadership, has primary responsibility for developing initiatives designed to address SDOH and patient population health disparities.
• Makes use of research and data to establish priority patient populations
• Collaborates with medical and quality improvement staff to establishes benchmark quality goals for each priority population group, and measures to evaluate service effectiveness
• In collaboration with Executive Director of Nursing, will explore future opportunities for wellness based integrated behavioral health programing  

• Participates in department management team meetings
• Participates in health center quality teams when assigned
• Acts as a liaison between the care coordination team, nursing department, the medical department, and other agency departments as needed
• Participates in other health center initiative and committees as assigned

•  Ensures that staff receive a comprehensive program orientation
•  Trains staff regarding the full range of their responsibilities
•  Provides ongoing guidance and supervision to assigned staff
•  Provides annual evaluations of assigned staff following agency evaluation guidelines

Requirements

• Education: Associate degree in nursing 
• Current Massachusetts Registered Nurse (RN) license degree required.
• Current CPR certification required
• Effective interpersonal and communication skills and ability to work harmoniously with diverse groups of individuals
• Experience working in an ethnically, culturally, and racially diverse environment
• Authentic interest in LGBTQIA+ and community health
• Proficient in the use of the computer and associated software, i.e., MS products 
• Ability to work harmoniously and effectively with colleagues, patients, clients and vendors across the spectrum of diversity, including but not limited to race, ethnicity, color, gender identity, sexual orientation, age, socio-economic status, national origin and immigrant status, religious or spiritual identity, disability (physical, mental, emotional and developmental), veteran status, and/or limited English proficiency.
• Willingness to contribute towards Fenway’s efforts in becoming an anti-racist organization and promoting a culture dedicated to ongoing development in service of humility, equity, diversity, inclusion, and belonging, where differences are acknowledged and valued.

• Bachelor’s degree level or higher in nursing
• Five (5) years of experience in ambulatory, hospital, or public health nursing
• Two (2) to Three (3) years of leadership experience
• Experience with working within a complex healthcare system with multiple product lines 
• Board Certification (ACRN, AMB-BC, etc)

1. OSHA Category 1: involves exposure to blood, body fluids, or tissues
2. Noise Level: usually conversational 

• Regularly required: sitting; using hands to manipulate objects/tools/controls; reaching with hands and arms; talking; hearing
• Frequently required: lifting and/or moving up to 10 lbs.
• Occasional required: lifting and/or moving up to 25 lbs.
• Vision abilities required: close vision, distance vision, peripheral vision depth perception, ability to adjust focus