The Nurse Case Manager (NCM) conducts comprehensive patient assessments to manage healthcare needs across the care continuum. This role aims to enhance individual health and self-management skills through a multidisciplinary team, including behavioral health and community health workers. Key responsibilities include performing in-office or hospital face-to-face visits for members requiring such interactions and assessments. The goal is to coordinate and facilitate services that meet member needs in accordance with benefit structures and available community resources. The NCM, alongside the interdisciplinary team, will develop patient care plans in collaboration with the patient, ensuring cost-effective and quality outcomes focused on the ambulatory setting. Embedded within provider offices, the NCM works closely with providers, office staff, care management staff, and community partners to manage member care. This person will support CHP’s mission, vision, and values and will adhere to compliance protocols as well as CHP’s policies and procedures.

• 2+ years of clinical experience as a Registered Nurse working with ages across the lifespan.
• Experience working with people that are on MassHealth coverage and may be encountering social, economic, and/or multi complex medical and or behavioral health conditions preferred.
• Understanding of hospitalization experiences and the impacts and needs after facility discharge required.
• Ability to communicate and collaborate with PCP, community and ACO partners to manage members care required.
• Experience with telephonic interviewing skills and working with a diverse population, which may also be non-English speaking, required.
• Home Health Care experience preferred.
• Experience working in a community social service agency, skilled home health care agency, State Agency such as the Department of Mental Health (DMH), Department of Developmental Services (DDS), Department of Children and Families (DCF), and/or the Department of Youth Services (DYS), or other agency servicing those in need preferred.
• Experience working face to face with members and providers preferred.
• Effective case management and care coordination skills and the ability to assess a member’s activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member’s need working in partnership with a care team preferred.
• Demonstrated ability to perform independently as a clinician with minimal supervision or assistance.
• Experience with self-scheduling of caseload preferred.