Edward M. Kennedy Community Health Center, Inc. Clinical Care Manager MAT RN in Worcester, Massachusetts
As part of a team-based approach to care, the Clinical Care Manager (CCM) provides, coordinates, and organizes evidence-based care management to Medication Assistant Treatment Program (MAT) patients.
Responsible for assisting Primary Care Providers (PCPs) in coordinating and managing the care of MAT program patients, ensuring that patients receive optimal care including acute illness and chronic disease management, education about lifestyle and behavior modification, and preventive care across multiple health settings with multiple providers
Manages care plans for patients admitted to and discharged from the hospital, patients seen the emergency room, and patients transitioning from or to any other health care facility with the objective of preventing further disease exacerbation, improving outcomes, increasing patient engagement in self-care, decreasing risk status, and minimizing hospital and ER utilization.
Identifies, manages, and coordinates patient care and provides ongoing communication to the care team regarding patient care, patient needs, plans of care, and changes in status
Provides direct patient care within the nursing scope of practice including, but not limited to, patient assessment, administration of vaccinations and medications, medication reconciliation, point-of-care testing, treatments, and lab and diagnostic test result review
Provides timely and informed patient triage
Involves the patient and their support systems in communication, care coordination, care planning, and education
Assists patients in building a patient action plan which includes self-management goal setting and a disease exacerbation prevention plan.
Utilizes behavioral strategies to assist patients in adopting healthy behaviors, improving self-care and managing chronic disease with a focus on educating and optimizing the member’s level of independence in navigating the healthcare system at all levels of the continuum.
Maintains a registry of MAT patients with documented completion of measures and interventions
Documents patient care, ongoing evaluation, patient progress/risk status, care manager interventions, and a plan of care developed with the PCP, in the EHR in accordance with health center and nursing standards
Participate in quality, compliance, and regulatory standards
Participates in the orientation and mentoring of new clinical staff as expertise
Education and Experience:
Registered Nurse License in MA
Bachelor’s degree in Nursing from an accredited college or university
1-2 years of clinical experience
Current CPR certification
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