Job Description

Position Purpose: Coordinates and manages care for the high and rising risk population through multiple care delivery systems, supporting patient in self-management of their health.

Essential Duties and Primary Accountabilities: Listing of the major functions of the role including percentage of time allocated to each function.

Should include all duties required to complete the job.

Coordinate and manage care of high risk population

  • Complete telephonic outreach and home visits as applicable based on patient acuity.
  • Performs a comprehensive care management assessment of patient needs to ensure optimal health outcomes.
  • Develops a self-management action plan of care, coordinates services and navigates the patient through the health care system with a goal of enabling the patient and family to effectively manage their condition(s) and optimize outcomes.
  • Coordinates effective transitions of care and effective handoffs to the next level of care across the entire continuum.
  • Collaborates with the patients care team including but not limited to hospital team, primary care team, specialists, home care, SHCN clinical programs, and any others involved with patients care and approved by the patient to ensure effective coordination of services and full understanding and execution of the care plan.
  • Maintains required medical documentation for care management activities in the system’s care management module (electronic medical records), according to the standards of work.
  • Follows standards of work and consistently maintains department established caseloads and timeframes for case completion.
  • Documents and reports all quality and patient safety events by recording and adhering to all of Steward Health Care Network’s safety reporting guidelines.
  • Performs other duties as assigned

Responsible for performance and/or oversight of daily ambulatory care management staff operations

  • Oversee case assignment and delegation for equitability and timely completion
  • Review time off requests and approve as necessary to ensure adequate staffing
  • Provide education to staff 1:1 and during tea meetings on topics impacting their day to day work
  • Implement staff performance plan as directed by manager
  • Provide feedback to manager on staff performance
  • Escalate any barriers to manager immediately

Process Improvement

  • Evaluates processes, identifies problems, and proposes improvement strategies to enhance the delivery of care for patients throughout continuum of care.
  • Escalates any barriers to positive outcomes to manager same day
  • Participates in the refinement of and development of new standards of work.
  • Maintains awareness of key performance indicators/metrics and manages caseload through appropriate management of medical expenses. Coordinates interventions to prevent adverse events such as ED visits, hospital admissions, and readmissions.
  • Attend staff meetings and education offerings both in person and via teleconference as required.

Education / Experience / Other Requirements


  • Graduate of a state-approved school of nursing.
  • Bachelors of Science in Nursing (BSN) preferred.

Years of Experience:

  • Minimum of 3-5 years’ relevant clinical nursing experience required.
  • 1-2 years prior management experience preferred.


  • Possess a current unrestricted RN license in the Commonwealth of Massachusetts and willing to obtain in other states as needed.
  • Must maintain Basic Life Support (BLS) certification.
  • Certified Case Management (CCM) or CCM eligible strongly preferred.

Work Related Experience:

  • Experience educating patients and families with self-management.
  • Creation and implementation of patient-centered care plans.
  • Utilization of motivational interviewing when engaging patients/families.
  • Proven leadership ability to influence, motivate, develop, and empower employees to achieve objectives with a team approach.

Specialized Knowledge:

  • Knowledge of chronic disease management
  • Understanding of Medicare and Medicaid regulations

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

Apply Online