Our Integrated Network brings together a diversity of experienced private practice and employed physicians as well as community and academic providers. While we are one unified network, we focus on different geographic regions, with local care teams convening to ensure healthy, happy neighborhoods throughout the greater Boston region.Location: Remote with occasional onsite travel Job OverviewThis position utilizesthe case management process and works closely with other members of the care team to help ensure that patients receive comprehensive and coordinated care through the continuum of care. This position is an integral member of the care team who conducts comprehensive clinical assessments, develops a patient-centered care plan, and engages the patient through motivational interviewing. The goal is to improve the quality of care and health outcomes for selected at-risk populations and promote the efficient delivery of health care services. Assesses, plans, implements, coordinates, and evaluates the plan of care in partnership with the patient/caregiver and other members of the health care team.Job DescriptionMinimum Qualifications:1. Massachusetts RN Licensure.2. Obtain appropriate state board where services will be provided as a registered professional nurse OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) within three (3) months of hire.3. Three (3) years of clinical experience in an acute care setting.4. Basic Life Support Certification OR Obtain within three (3) months.Preferred Qualifications:1.Bachelor’s degree.2.Five (5) years of experience in acute, subacute, or home care, palliative care and hospice experience a plus.3.Case Management certification and experience.4. Bilingual.5.Valid driver’s license in current state of residence.Duties and Responsibilities: The duties and responsibilities listedbelow are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.1.Prepares for patient interaction by gathering information from the patient’s medical record, when available, and communicating with the healthcare provider and other clinical team members.2. Coordinates all aspects of care for patients across the continuum of care. Advocates for patient needs and negotiates for services as required to provide cost effective and quality care.3. Develops trusting, professional, caring relationships with patients and families, engaging respectfully and with an emphasis on service.4. Acts as lead member of multidisciplinary patient care teams, including collaboration with the healthcare provider and patient/caregivers as appropriate.5. Performs patient assessments to identify and prioritize the patient’s medical needs, behavioral health conditions, health system resources and social determinants, while also identifying patient’s knowledge gaps.6. Makes home or site visits as required.7. Establishes goals that are patient specific and identified as part of the patient’s self-management goals.8. Communicates with health care providers on behalf of patients/caregivers as needed and as requested by the patient, including communicating abnormal findings and patient concerns in a timely and thorough manner.9. Conducts medication reconciliation and provides education and consults with the pharmacist as needed.10. Develops patient-centered care plans with the patient/caregiver, providing all information to the healthcare provider, and establishesappropriate timelines for achieving identified goals.11. Updates the patient care plan as changes in status occur and communicates with the healthcare provider and other members of the treatment team as indicated.12. Participates in quality improvement activities to enhance clinical and operational initiatives and programs.Physical Requirements:1.Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc.2.This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending / descending stairs and operate office equipment.3.Frequently required to speak, hear, communicate and exchange information.4.Able to see and read computers displays, read fine print, and/or normal type size print and distinguish letters, numbers and symbols.5.Occasionally lift and/or move up to 25 pounds.Skills & Abilities:1.Familiarity with the target community and feels connected to that community.2. Excellent interpersonal, conflict resolution, and communication skills telephonically as well as face-to-face.3. Demonstrate ability to work well with people of various ages, backgrounds, ethnicities, and life experiences.4. A robust understanding of management of chronic health conditions and population management.5. Familiarity with Motivational Interviewing.6. Ability to prioritize and resolve critical issues efficiently and effectively.7. Detail oriented, with strong organizational skills and multi-tasking abilities.8. Very strong working knowledge and proficiency with technology and business software (Microsoft Office).9. Experience with Electronic Medical Records and possess a willingness and ability to learn and utilizenew technology and procedures that will continue to develop in their role and throughout the organization.10. Ability to work independently with minimal supervision and as part of a team.Job Profile Summary This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Care Manager related duties: Works as part of a multidisciplinary team to coordinate their patient's care in an effort to improve patient outcomes and create efficiencies. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience. Typically responsible for: managing projects / processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems. Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at .