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Boston Health Care for the Homeless Program Nurse Care Manager in Boston, Massachusetts

Since 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 11,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Our clinicians, case managers, and behavioral health professionals work in more than 35 locations to serve some of our community’s most vulnerable—and most resilient—citizens.

From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all. We provide community-based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face.

Bilingual, Bicultural, LGBTQIA identifying, Black, Indigenous, and People of Color are encouraged to apply .

To learn more about working at BHCHP, watch our video Please Click Here (https://www.bhchp.org/careers)

Job Summary:

In this role, you will serve as a vital member of a multidisciplinary team responsible for linking homeless individuals with serious mental illness, substance use disorders, and/or complex medical illnesses with primary and mental health care, substance use treatment, and case management to help address the social determinants of health. This work is a part of a new MassHealth initiative that provides eligible MassHealth enrollees with a service benefit called Behavioral Health Community Partners. You will collaborate closely with a multidisciplinary care team, including providing clinical support to 3-5 Care Coordinators with caseloads of approximately 45 patients each. As the Nurse Care Manager, you and the Care Coordinator from the BH CP Care Coordination Team will collaborate with the broader care team (PCP, BH clinicians, etc.) to ensure that the enrollees are receiving needed services and measuring progress towards the goals outlined in their patient-centered care plan.

Responsibilities:

  • Provides clinical support to case managers/care coordinators for a primary care panel. This includes chronic disease management and medication monitoring.

  • Engages vulnerable populations as part of a multidisciplinary outreach team. This includes home visits, outreach to hospitals, homeless shelters and other settings, as needed.

  • Provides clinical oversight and tracking for comprehensive intake assessments.

  • Participates in developing patient-centered care plans for the BH CP enrollees on their panel. Approves initial plan and biannual updates.

  • Works with BHCHP staff at Boston-area hospitals to coordinate hospital admission/discharge plans with the behavioral health clinician, PCP, ACO, MCO etc.

  • Performs timely medication reconciliation following transitions in care. Supports medication adherence.

  • Uses data to evaluate outcomes from targeted interventions for approximately 165 patients. Assists in developing appropriate adjustments to care plans based on this data.

  • Provides health coaching for groups of enrollees or individual enrollees as needed.

  • Implements prevention & engagement activities working with BH CP Team Coordinator. Engages in quality improvement efforts, as led by the Team Coordinator.

    Qualifications:

  • Licensed or eligible to be licensed as a Registered Nurse in the Commonwealth of Massachusetts.

  • 5 years nursing experience with complex patients; BSN preferred but not required.

  • Bilingual skills in Spanish and English preferred.

  • Experience working with vulnerable populations, including persons with a history of trauma, those experiencing socioeconomic stress, homelessness, or substance use disorders.

  • Strong interpersonal skills and clinical problem solving; flexibility and strong multitasking skills.

  • Comfort working in an autonomous clinical setting and nursing in an outreach setting.

  • Capability working with data to track and measure performance.

  • Computer skills: Proficient with Microsoft Excel Spreadsheets, entering narrative and other data into a database, Epic HER.

    Compensation and Benefits:

    The compensation starts at $31.11 per hour and increases based on years of experience.

    BHCHP full time employees are eligible for our competitive time off policy of 4 weeks’ vacation, health, dental and vision insurance, 403B retirement savings plan and employer retirement contribution, and pre-tax MBTA pass program with 40% discount. In addition, eligible employees will receive yearly increases, additional compensation for demonstrated bilingual proficiency and the opportunity to work with local hospitals and community health centers.

    Does this amazing opportunity interest you? Then we'd love to hear from you.

    As an Equal Opportunity Employer, BHCHP pledges not to discriminate against and encourages those from underrepresented and underserved backgrounds to apply, particularly Black, Indigenous, and People of Color (BIPOC), LGBTQIA identifying, first generation college students and adults without a college degree, Bilingual and Bicultural persons; and individuals from low economic backgrounds.

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