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Reliant Medical Group – Holden, MA

Reliant Medical Group is seeking a Chronic Nurse Case Manager to join our exciting and innovative team!
Department: Care Management Position: Full-time 40 hours per week Hours: Monday - Friday 8:00AM - 4:30PM No weekends or holidays
Manages all aspects of patient centered care for a panel of patients with identified needs, while working as part of a health care team (Providers, Nurses, Social Workers, Patients, Family,
Caregivers, etc)
  • Provides comprehensive case management and care coordination for a panel of patients with identified needs. Coaches (rather than teaches) patients to improve their health behavior to attain health-related goals.
  • Completes a comprehensive patient needs assessment for each patient.
  • Develops and communicates (with patient, caregiver and primary care physician/health care team) a comprehensive care plan based on evidence-based best practice for chronic illness.
  • Proactively manages and follows-up (using home visits and telephone calls) according to careplan.
  • Manages and coordinates all transitions of patients care.
  • Communicates care plan to all providers in all settings of care (emergency department (ED), hospital, rehabilitation facility, nursing home, home care and specialist).
  • Ensures that relevant providers receive timely clinical data for care treatment decisions in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care, and specialty care).
  • Directs caregiver support, including ad hoc telephone advice.
  • Facilitates patient and caregiver access to community resources relevant to patient needs, including referrals to transportation programs, Meals on Wheels, senior centers, chore services,etc.
  • Incorporates self-care and shared decision making in all aspects of patient care.
  • Complies with health and safety requirements and with regulatory agencies such as DPH, etc.
  • Complies with established departmental policies, procedures, and objectives.
  • Enhances professional growth and development through educational programs, seminars, etc.
  • Attends a variety of meetings, conferences, and seminars as required or directed.
  • Performs other similar and related duties as required or directed.
  • Regular, reliable and predicable attendance is required.
  • Graduate from an accredited school of nursing.
  • Active, unrestricted licensure as a RegisteredNurse in Massachusetts; current Massachusetts drivers license.
  • Certified in Geriatric Nursing or Geriatric Case Management preferred.
  • A minimum of five years nursing experience, preferable with older patients.
  • Excellent communication, interpersonal and organizational skills, with a flexible and creative approach to problem solving.
  • Works effectively both independently as well as a member of an interdisciplinary team.
  • Proficient in computer use, the Internet and health information technology.
  • Ability to travel to hospitals, skilled nursing facilities, patients homes,and other sites where patients receive care as needed.

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