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Community Nurse Care Manager

Westwood, Massachusetts

Department: BIDCO

At Beth Israel Deaconess Medical Center our nurses make a difference each and every day. Here you will work in a collaborative environment where our patients come first. You are a patient advocate delivering compassionate care while ensuring safe nursing practices. We are Harvard with a heart and strive to build on our legacy of nursing excellence.

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Success Profile

  • Team Player 10
  • Adaptable/Flexible 9
  • Patient Focused 8
  • Self Confident 8
  • Dependable 7
  • Compassionate 7
Traits are on a scale of 0 to 10

Additional Traits

  • Proactive
  • Problem-Solver
  • Positive
  • Motivated
  • Committed
  • Self-Starter

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Let me just give you a quick overview of why it's different here. You'll be heard, respected, valued. Your ideas will be sought, your input welcomed. There's a real commitment to keeping it collegial and collaborative.

-Marsha M., RN, MS, Senior Vice President, Patient Care Services CNO


  • Collaboration

  • 401k/Retirement Savings

  • Continuing Education

  • Amenities

  • Health and Wellness Programs

  • $5 Red Sox Tickets

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Department Description: Hours = Full-Time (with Benefits) based on 40-hours per week, Day shift, Monday-Friday. Population Health - Beth Israel Lahey Performance Network. Behavioral Health experience is preferred.

Job Location: Westwood, MA

Req ID: 30732BR

Job Summary: The primary responsibility of the BIDCO Community Nurse Care Manager (NCM) is to provide community based care management support to medically complex Medicare ACO, Medicare Advantage, and commercially insured risk patients. The goals of care management are to provide evidence-based, efficient, and cost effective support and care coordination to our core customers - patients and providers - thus enabling us to reduce potentially avoidable utilization of health resources such as hospital admissions, readmissions, and ED visits and to maintain and grow our reputation for clinical excellence.

Essential Responsibilities:
  1. Provides community based care management to medically complicated, high risk patients who are identified through predictive modeling, physician referral, and other involved care givers. This includes but is not limited to patients with certain chronic conditions and co-morbidities such as diabetes, CHF, COPD, and dementia.
  2. Develops an individualized care plan for the patient and family caregivers based on a comprehensive assessment done via telephone or face-to-face in the PCP practice or patient home.
  3. Manages a caseload of approximately 80 patients/FTE concurrently, and approximately 240 patients/FTE per year.
  4. Tracks and monitors patients under caseload through all transitions of care. This includes to and from the hospital, rehab, SNF, palliative care, and hospice. Coordinates and arranges community services as needed, such as home health, elder services, and SNF waiver.
  5. Communicates and collaborates with other health team providers including PCP, specialists, visiting nurses, hospital case managers, SNF discharge planners, SNF LOS care managers, , community resource specialists, etc.
Required Qualifications:
  1. Graduate from an accredited Nursing Program required. Baccalaureate degree in Nursing strongly preferred.
  2. License Registered Nurse required., and Certificate 1 Basic Life Support preferred.
  3. 3-5 years related work experience required.
  4. Ability to travel within Massachusetts to assigned practices on a regular basis.
  5. Experience with computer systems required, including web based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint or Access.
Preferred Qualifications:
  1. Behavioral Health experience preferred.
  2. Homecare and/or case management experience preferred.
  3. Knowledge of and experience with community resources. Ability to create community based plans of care for patients and families utilizing these resources preferred.
  1. Decision Making: Ability to make decisions that are guided by general instructions and practices requiring some interpretation. May make recommendations for solving problems of moderate complexity and importance.
  2. Problem Solving: Ability to address problems that are highly varied, complex and often non-recurring, requiring staff input, innovative, creative, and Lean diagnostic techniques to resolve issues.
  3. Independence of Action: Ability to set goals and determines how to accomplish defined results with some guidelines. Manager/Director provides broad guidance and overall direction.
  4. Written Communications: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.
  5. Oral Communications: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.
  6. Knowledge: Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations.
  7. Team Work: Ability to work collaboratively in small teams to improve the operations of immediate work group by offering ideas, identifying issues, and respecting team members.
  8. Customer Service: Ability to provide a high level of customer service and staff training to meet customer service standards and expectations for the assigned unit(s). Resolves service issues in the assigned unit(s) in a timely and respectful manner.
Age based Competencies:
Employees in this job must be competent to provide patient care to the following age groups: Young adult: 16-30 years, Middle Age: 30 - 60 years, Elderly: 60 -.
Physical Nature of the Job:
Light work: Exerting up to 20 pounds of force frequently to move objects. Some elements of the job are sedentary, but the employee will be required to stand for periods of time or move through out the hospital campus

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