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MelroseWakefield Hospital · 1 month ago

Care Manager - Adult General Internal Medicine - Boston

Tufts Medical Center

Full-time

Onsite

Mid, Senior Level

$41.76/hr - $68.89/hr

3+ years exp

MelroseWakefield Hospital is seeking a Care Manager for Adult General Internal Medicine. This role involves providing comprehensive nursing care, conducting clinical assessments, and developing patient-centered care plans in collaboration with healthcare teams to ensure optimal health outcomes.

Health CareHome Health CareMedical Device

Responsibilities

Prepares for patient interaction by gathering information from reviewing the patient's medical record when available and communicating with the PCP and other members of the health care team. Completes assessments upon enrollment, transition in care and changes in health status

Coordinates all aspects of care for patients through continuum

Assesses the child/family to obtain information to identify and to prioritize, in partnership with the families, the child’s health conditions and establish goals that are patient specific. This includes self -management goals

Communicates abnormal findings and concerns in a timely manner to the provider/other members of the care team. Complete a clinical summary to provider

Conducts medication reconciliation with every transition of care and provides education and consultation with Pharmacist

Develops a care plan with the patient, family; providing all information to the PCP and the health care team

Conducts home assessments to address health care needs especially home safety needs

Documents the assessments, interactions and the care plans within the EMR. Adheres to documentation standards

Utilizes identified teaching materials and evidence based best practice for teaching patients/families/community

Undertakes quality improvement activities to improve the care management program

Participates in team meetings; provides updates on program status and to identify challenges and opportunities

Maintains collaborative, team relationship working with TMIN staff and all affiliated agencies. Works with Medicare and commercial population

Possesses and applies the skills and knowledge necessary to plan for and provide care to patients and their families throughout the life span, with consideration of developmental age as well as chronological age. Ability to work effectively with children and families that reflect the full diversity of family structures, cultural patterns, spiritual beliefs and communities. This includes: Knowledge of growth and development; Ability to interpret age specific data and response to care; and Provide age specific communication

Qualification

Registered Nurse (RN) licenseCare management experienceBasic Life Support (BLS)Bachelor of Science in Nursing (BSN)Certified Case Manager (CCM)Family centered careInformation Systems proficiencyCommunity resourcesOrganizational skillsCommunication skillsTeamwork