Clinical Care Manager RN

Established in 1977, Vinfen is a nonprofit, health and human services organization and a leading provider of community-based services to individuals with mental health conditions, intellectual and developmental disabilities, brain injuries, and behavioral health challenges. Our services and advocacy promote the recovery, resiliency, habilitation, and self-determination of the people we serve. Vinfen's 3,500 dedicated employees are experienced, highly-trained professionals who provide a full range of supportive living, health, educational, and clinical services in over 550 sites throughout Massachusetts and Connecticut. For more information about Vinfen, please visit www.vinfen.org/careers.

This position is remote. Candidates must live within 100 miles of Boston, MA to attend necessary trainings/meetings. The Clinical Care Manager (CCM) RN provides intensive care coordination and clinical care management for MassHealth Members with complex medical and behavioral health needs who are enrolled in an Accountable Care Organization (ACO) or Managed Care Organization (MCO) plan. The CCM collaborates with their respective Community Partner team and the clinical staff of each Enrollee’s ACO/MCO’s plan to minimize duplicative efforts, promote integrated care, ensure quality and continuity of care, and support the values of person-centered planning, Community First and SAMHSA Recovery Principles. The CCM is at the helm of organizing and coordinating resources and services in response to the Enrollee’s healthcare needs across multiple settings, and inclusive of both LTSS and Social Determinants of Health (SDH) needs. This role drives outreach and engagement, assessment and care planning, care transitions, health and wellness coaching, as well as community and social services connections in partnership with Enrollees and their care teams.

Provides outreach to and engages with enrollees referred for CP program as assigned by Team Leader or Director. Conducts comprehensive assessment of enrollees including the medical, psychiatric and social issues of enrollees served. Reviews/approves medical components of comprehensive assessment for Care Team enrollees. Organizes and facilitates the effective functioning of the Interdisciplinary Care Team (ICT), including coordinating meetings, facilitating communication, and documentation. Reviews, analyzes, and tracks incident reports to identify patterns, trends, and potential risks to enrollee safety: collaborate with interdisciplinary teams to investigate adverse events, develop corrective actions, and implement quality improvement strategies in alignment with risk management protocols and organizational policy Monitors the enrollee’s health status and needs and provides nursing and medical care coordination, including revising health related treatment goals and plans in collaboration with the enrollee and the team. Coordinates the development, implementation, monitoring, and review/approval of enrollee care plans. Collaborates closely with PCP and other Providers including, but not limited to community resources, and assures appropriate referrals based on level of care needed to optimize outcomes and minimize risk. Performs other related duties, as assigned.