General Definition and Scope of Job

The Nurse Care Manager is responsible for performing care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their health needs.


Core Responsibilities

  1. Interviews patients for complete medical histories. Designs a plan of care based on assessment of physical, mental and social needs and in collaboration with the patient and family.
  2. Interprets the plan of care to the patient and the family; and facilitates follow-up patient care when indicated.
  3. Keeps informed of and utilizes supportive services and referral channels for the accomplishment of quality care.
  4. Collaboratively works with other caretakers toward patient education and rehabilitation including promotion of mental and physical health.  Current health information and materials are to be made available to the patient and family. This includes participation in the development of patient education material.
  5. Assumes responsibility for close surveillance of patients undergoing therapy requiring technical knowledge and skill e.g. insulin therapy.
  6. Appropriately documents and communicates patient’s needs through symptoms, objective signs, assessments and plans.
  7. Serves as patient advocate.


Care management responsibilities

  1. Team Leader: Assists providers with care coordination and guides other members of the healthcare team to improve outcomes.  Meets with team members and providers to review care plans and next steps.
  2. Care Coordination:  Supervises outreach to patients who frequent ED.  Assist selected patients with achieving health maintenance goals, chronic disease care, and navigation to social service agencies for psycho-social issues and connection to primary care.  Engages in relationship building with patients.
  3. Patient Self-Management:  Educates patients about their medical conditions such as asthma, diabetes, CVD and COPD.  Teaches skills such as blood sugar testing, insulin administration, peak flow and inhaler use and eliminating asthma triggers.  Gives support for medication adherence and therapeutic compliance.  Connects patients to community resources to support goal setting and care plan.
  4. Education:  Supports the AADE Diabetes Self-Management Education Program.  Professional Development:  Is a resource person and leader in guidance to other health center staff.  Teaches and directs staff according to evidence-based guidelines for chronic disease care.  Understands basic nutrition issues for diabetes and CVD.  Remains eligible to teach under ADA recognition and asthma education guidelines.
  5. Technology:  Uses EMR and registries to create reports to direct improvement activities of teams and communicate progress to health center staff.  Competence in EXCEL.
  6. Performs other appropriate job duties as assigned.


Minimum Skills, Experience and Educational Requirements

Graduate of an accredited school of nursing.

  • Has knowledge of nursing and medical principles including disease processes, certain examinations, observations, laboratory studies; and appropriately applies those principles to practice and procedure
  • Possesses and displays the ability to act independently within the scope of the Nurse Practice Act and consistently utilizes good judgment in patient care and the resolution of problems both clinical and non-clinical
  • Maintains professional composure and confidence during stressful situations
  • Demonstrates self-direction and motivation in activities which enhance patient care. Anticipates new problems and is part of the problem solving process


Required Certifications and Licenses

  • Massachusetts license to practice professional nursing
  • Preferred BSN for RN
  • Previous experience in ambulatory care or public health preferred but not required
  • Current CPR certification


Critical Demands of the Job

  • Manage multiple requests and prioritize appropriately
  • Ability to function in a fast paced setting with a variety of patients and staff
  • Attention to details and prompt follow up
  • Includes walking and standing for long periods of time, sitting for short periods of time, hand dexterity, clear hearing and speaking ability. Must be able to lift a maximum of 1/3 of their body weight
  • Excellent organizational and interpersonal skills


Working Conditions

  • Works in well-lighted environment with comfortable surroundings
  • Stressful at times due to competing demands, including attention to multiple patients and staff
  • Will comply with all applicable laws, and will cooperate with the Manet Community Health Center/South Shore Hospital compliance program rules and regulations


Required Availability

May be required to work a rotating schedule as the department requires. This includes different sites, evenings, holidays and weekends.