Established in 1980, the Greater Lawrence Family Health Center, Inc. (GLFHC) is a multi-site, mission-driven, non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to a culturally diverse population throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program.
GLFHC is currently seeking a RN, Care Manager to join our Team. The RN Care Manager serves as an integral member of the healthcare team to improve the clinical and operational performance for a subset of assigned patients, namely those with HIV, viral Hepatitis and Substance Use Disorder (SUD). The role will focus on organizing, planning and coordinating the delivery of care as provided by the healthcare team; and providing nurse care services such as follow up visits, medication teaching and monitoring. As a case manager, the RN Care Manager will be responsible for coordinating care for a set number of patients as well as ensuring the care meets standard quality measures. The RN Care Manager will facilitate access to care and retention in care, consistent with Massachusetts Department of Public Health, Boston Public Health Commission established Standards of Care, and the Bureau of Substance Abuse Services.
Clinical Care Activities
Conducts an intake on all new patients; implements a culturally competent plan of care that will help the client achieve their health goals and evaluates the plan per disease protocol.Provides initial and ongoing education on HIV and viral Hepatitis; counseling on harm reduction and adherence support.Leads the Comprehensive Care Clinic (HIV) and Viral Hepatitis clinic by preparing a pre-visit document, scheduling patients, managing clinic flow, and coordinating services for the patient. Provides patient care (adherence assessment, education and counseling, immunizations) in these specialty clinics.Documents each contact with patient or outside agency in the EMR according to protocol.Utilizes ascribed processes for managing the needs of complex patients, initiating interventions based on physician approved patient-specific protocols and order sets.Provides direct patient care, if indicated and approved by the manager, which may include immunizations, phlebotomy, and directly observed therapy.At the request of the patient, participates in or facilitates partner notification and family education.Regularly assess progress toward goals and identifies patients who are not adhering to their medical plan (medical visits, laboratory evaluations, pharmacy pickups) and provides outreach, including home visits, to assess barriers to care, provide education and counseling and assists client in accessing medical care and treatment.Remains current on basic principles of HIV and viral Hepatitis.Coordination of Care Activities:
Coordinates patient care with other members of the medical team, including PCP, HIV and HCV specialist, medical case manager (CHW), nutritionist, pharmacist, and any other members of the team.Coordinates and/or provides outreach efforts to new patients to assist them engage in care.Assesses progress toward goals based on clinical judgment and review of trends in clinical data.Maintains an up-to-date client list with relevant quality indicators.Prepares documentation for HIV and Hepatitis case conference and participates in case discussions.Coordinates client care during transitions, such as intakes, discharge, institutionalizations (i.e. correctional facilities), hospitalizations, etc.Qualifications:
Massachusetts Registered Nurse License.Current BLS certification.Minimum of 2 years’ experience in case management or care coordination preferred.Knowledge of clinical and cultural issues involved in the care of Latino, African American and gay, lesbian and transgender as well as those with substance abuse.Strong clinical and assessment skills.Bilingual Spanish/English strongly preferred.Outstanding communication skills, self-motivation, organization and flexibility; commitment to improve care in underserved population; collaborative work style; relationship building by meeting directly with patients, families and providers in various settings; high level of accountability; reliable transportation; computer skills.Valid Massachusetts Driver’s license and access to reliable transportation.GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.
Read LessFounded in 1980, Greater Lawrence Family Health Center (GLFHC) is a mission‑driven, multi‑site nonprofit serving residents across the Merrimack Valley. With a staff of over 700, GLFHC is dedicated to providing high‑quality, compassionate, and accessible patient care. Our Community‑Based Services focus on meeting individuals where they are through evidence‑based, person‑centered approaches that reduce harm, improve health outcomes, and connect people to supports without judgment or unnecessary barriers. Through our programs, we provide counseling, treatment referrals, immunizations, and harm reduction services, including syringe access and Narcan education.
GLFHC is currently seeking a CSS, Nurse Care Manager to join our Community Based Services team. Teh CSS, Nurse Care Managers erves as an integral member of the healthcare team to improve the clinical and operational performance of a subset of assigned patients. The role will focus on assessing, organizing, planning and coordinating the delivery of care in conjunction with the healthcare team; and providing nursing services such as follow up visits, medication administration, medication teaching and monitoring. In addition to being responsible for clients assigned to care manage, this role is responsible for ensuring the care meets standard quality measures as dictated by the regulatory and funding agencies. The CSS, Nurse Care Manager works in person with some remote options available dependent on program and patient needs.
Care Management Activities
Conducts an intake on all new patients; in conjunction with the patient, implements a culturally competent plan of care that will help the client achieve their health goals and evaluates the plan per disease protocol.Provides initial and ongoing education on the relevant disease state and counseling on prevention, harm reduction and adherence support.Coordinates patient care with other members of the medical team, including PCP, specialist, MA and CHW care manager, recovery coach/peer, nutritionist, pharmacist, and any other members of the team.Coordinates and/or provides outreach efforts to new patients to assist them engage in care.Assesses progress toward goals based on clinical judgment and review of trends in clinical data.Maintains an up-to-date client list with relevant quality indicators. Case loads range between 100 -150, depending on the acuity of the clients and the disease state.Prepares documentation for case conference and participates in case discussions.Coordinates client care during transitions, such as intakes, discharge, institutionalizations (i.e. correctional facilities), hospitalizations, etc.Utilizes ascribed processes for managing the needs of complex patients, initiating interventions based on physician approved patient-specific protocols and order sets.At the request of the patient, participates in or facilitates partner notification and family education.Regularly assess progress toward goals and identifies patients who are not adhering to their medical plan (medical visits, laboratory evaluations, pharmacy pickups) and provides outreach, including home visits, to assess barriers to care, provide education and counseling and assists client in accessing medical care and treatment.Documents care management and utilizations in accordance with the program requirements in external systems in addition to the EMR.Clinical Activities
Participates and Leads the specialty clinics by preparing a pre-visit document, scheduling patients, managing clinic flow, and coordinating services for the patient. Provides patient care (adherence assessment, education and counseling, immunizations) in these specialty clinics.Conducts follow up nursing visits for patients as relevant.Documents each contact with patient or outside agency in the EMR according to protocol.Provides direct patient care which may include immunizations, phlebotomy, and directly observed therapy via injectable and or oral medications.Remains current in the diagnosis, treatment and management of specialty condition, including pursuing CME’s and advanced certification as appropriate.Administrative Activities
Follows established GLFHC and CSS policies and procedure as well as regulatory policies.Adheres to contractual program and reporting requirements.Attends regular CSS and nursing meetings and seeks supervision when in doubt as to programmatic, legal or other issues.Participates in department, health center, and other meetings as assigned. Is knowledgeable and respectful of the client’s privacy rights, including but not limited to federal and state regulations and consistently observes HIPAA.Travel between sites is required.Maintains licensure and remains current on disease-specific standard of care.Develops a professional development plan with supervisor and updates annually.Qualifications:
Minimum of 2 years’ experience in nursing care.Valid CPR certification.Bilingual Spanish/English strongly preferred.Experience in care management or care coordination preferred.Knowledge of clinical and cultural issues involved in the care of Latino, African American and gay, lesbian and transgender as well as those with substance abuse.Strong clinical and assessment skills.Outstanding communication skills, self-motivation, organization and flexibility; commitment to improve care in underserved population; collaborative work style; relationship building by meeting directly with patients, families and providers in various settings; high level of accountability; reliable transportation; computer skills.Valid Massachusetts Driver’s license and access to reliable transportation.Education:
Massachusetts Registered Nurse License (unexpired). Read LessEstablished in 1980, the Greater Lawrence Family Health Center (GLFHC) is a multi-site mission-driven non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to residents throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program.
GLFHC is currently seeking a Registered Nurse (RN) Care Manager (CM) to join our care management team. The RN, Care Manager will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic conditions, many of whom also face multiple barriers in their lives which makes it difficult for them to achieve the self-care required to improve their health and well-being. This position requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in person in a variety of potential settings such as but not limited to, the health center, community, home, or an inpatient facility. This role is a hybrid model with remote opportunities and onsite presence at local practice locations for team meetings is expected.
Conducts Comprehensive Assessments on all patients referred into the complex care management program and formulates individualized care plans based on the patient’s needs and preferencesImplements interventions and revises care plans as needed based on ongoing patient assessment and evaluation, including following any inpatient discharge or ED visitFacilitates patient outreach to assess the patient’s progression toward their goalsUses motivational interviewing strategies to optimize patient engagementConducts medication assessments and reconciliation as appropriate and refers to the care team pharmacist as needed based on assessmentProvide care coordination, which may include but not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-upFacilitates case conferences as needed, including engaging community partners and other community based stakeholders who are engaging with patientsMay be required to meet patients while they are inpatient to provide education and support about the discharge process and transition members into care management.Assesses the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support including symptom response plans based on the member’s needs and preferences.Refers/connects patients with primary care, behavioral health, flexible services, Community Partner, respite, and other community based social services as indicated and appropriate.Qualifications:
Bi-lingual Spanish speakingLPN/RN with active Massachusetts licenseLicensed Practical Nurse (LPN) with Care Management experience, ASN (Associate degree in Nursing) or bachelor’s degree in Nursing (preferred)Case Management Certification (CCM, ANCC RN-BC) preferred3-5 years of nursing experience, preferably in-home health, ambulatory care, community public health, case management, coordinating care across multiple settings and with multiple providersValid driver’s license#GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.
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