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The RN coordinates care for vulnerable patients with opioid dependence and chronic pain, focusing on acute and chronic disease management. Responsibilities include triaging patients, conducting medication reconciliation, and facilitating transitions between health settings.
Requirements summary
Requires an Associate Degree in Nursing and a valid MA State RN license, with BLS certification required. A minimum of two years of experience in case management, disease management, or home health care is necessary.
The RN is an integral part of the multidisciplinary care team responsible for ensuring that the primary care provider and practice team maintains a central role in the care process, by coordinating the care of these vulnerable patients, and ensuring the patients receive optimal care including acute illness management, chronic disease management, self-management coaching, and wellness/preventive care as they transition across multiple health settings and/or multiple physicians/providers.
Program Specific Essential
Duties and Responsibilities
With the Team Leader, engages in daily team huddles by providing andsolicitinginput from other team members to enhance the team’s performance for patient care. Huddles include information and follow up tasks for patient care.
Triages patients in person and by phone for patients who require immediate intervention including medication difficulties, urgent careappointmentsand hospital admissions.
Providestimelyandfrequentcommunications with the PCP and practice team to maximize the management of patient needs and related risk reduction.
Documents the patient care discussion in the integrated care plan or plan of care.
Works with team members to follow up on test results and referral results that are needed for decision making asappropriate forthe integrated care planning process. Ensures that results are communicated with community services, health plans, facilities, and specialists.
Follows the pre-approved protocols specific to population (e.g.Suboxone,Vivitrol)
Supports self-management of patients’ healthissueby usingevidence basedapproaches such as health coaching and motivational interviewing.
Assistspatient/family in self-management skills toidentifyproblems, make decisions about the illness, preventative care, using resources, developing partnership withprimarycare provider team, andtaking actiontowards their goals.
Assiststhe patient/family or other support member with coaching or through a referral.
Coachespatients/families towards goals by active participation in their plan of care, goal setting, identifying/removing barriers, problem solving, andidentifyinga plan for follow through (e.g.visits, phone calls).
Provides emotional support and documents evidence ofpatient’sinvolvement in their care.
Identifiesfactors that are barriers to care for the underserved and vulnerable population (e.g.lack of housing, transportation, health literacy, language barriers)
Addresses the health needs and management of a specific population (e.g.patients with opioid dependence,Coordinatescareand trackspatients experiencing a transition to or from care facilities, and/or providers;assistsintwo-way communication between the PCP, specialists, and/or otherspecialtyproviders.
Coordinates care with behavioral health services, specialty care, inpatient services, and non-clinical support in the community
Communicatesin a timely manner(e.g.within 24-48 hours) with patients during transitions such as beingdischarged froman inpatient setting of the hospital. Follow-up for patients who have Emergency Room visits when these patients are currently being followed by a Care Manager. This communication isto prevent readmission and related complications.
Provides a smooth transition for same day or urgent visits between patient and multidisciplinary team
Qualifications: and Education Requirements:
One of the following combinations of education and employment experience must be met in order to be considered for the position:
Education
And
Experience
Associate Degree in nursing required. A nurse with a BS or Master’s Degree preferred.
Minimum two years’ experience in case management, disease management, home health care nursing, or intensive outpatient education and/or self-management support. Experience with Special Populations preferred
Licensed RN by MA State Board of Registration. BLS required; ACLS preferred. Certified managed care nurse or registered nurse case manager preferred.
