Care Manager, Chronic Disease

Lynn, MA | Nursing-Other


The Care Manager serves as an integral member of the primary care team in the Patient Centered Medical Home model. As part of the physician-led Medical Home team, the Care Manager works closely and collegially with physicians, associate providers, clinical and administrative staff and collaborates to enhance the delivery of patient care services along the continuum of care.

The Care Manager will: follow a panel of primary care patients with chronic disease management needs who will be identified using new risk-stratification technology; provide both episodic and ongoing education and coaching for chronic disease management using evidence based guidelines; work closely and collaborative with other disciplines to enhance care coordination, including: behavioral health, social work, and community resource specialists; and assist with patient care transitions; including visits to specialists, visits to the Emergency Department or Urgent Care, admissions to inpatient and extended care facilities; and transitions to different models of care, such as long-term care or hospice.

The Care Manager will also serve as a resource to clinical services through mentoring and assisting with quality initiatives. Through broad knowledge of clinical care and systems management, the Care Manager will meet the patients' needs efficiently and expeditiously by continuously working to improve the patient experience, ensure high quality patient care, and reduce cost.

Essential Duties and Responsibilities; include the following, other duties may be assigned.

In collaboration with the Patient Centered Medical Home team :

- Works closely with all members of the Medical Home team to provide an environment that supports patient self-management and improved patient outcomes.

- Follows a panel of primary care patients with chronic disease management needs who will be identified through a population management registry
- Use worklists and quality measures to track patients with care needs and clinical outcomes
- Oversee patient outreach and monitoring
- Delegates outreach tasks as appropriate to other clinical or clerical staff

- Assists patients and families with self-management of chronic diseases, including but not limited to: Hypertension, Diabetes, Hyperlipidemia, Obesity, CHF, COPD, Asthma, and Depression.
- In conjunction with the patient's PCP, the patient, family and other members of the Medical Home team, collaboratively develops a comprehensive plan of care, including treatment and self-management goals that are to be reviewed at every relevant visit.
- Assist patients with goal setting and behavioral action plans
- Implements the plan of care in a timely manner, appropriately utilizing insurance-approved community- and practice-based services.
- Ensures that all elements critical to the plan and trajectory of care have been communicated to the patient, family and members of Medical Home team.
- Provides the patient and family with a written or secure electronic version of the plan of care.
- Provides both episodic and ongoing patient education and coaching for chronic disease management using evidence based guidelines; using both office-based and virtual (telephonic or electronic) visits.
- Assesses patient and family self-management abilities and provides patients and families with self-management tools to record self-care results
- Assesses and addresses barriers to patient self-management and medication adherence when the patient has not met treatment goals.
- Assesses patient and family understanding of treatment goals and medications.
- Provides educational resources to patients and families to assist in self-management
- Monitors the patient's progress, intervening as directed by the physician or as appropriate through standing orders or protocol.

- Assesses patient/family continuing care needs in collaboration with the Medical Home team.
- Identifies patients/families with complex psychosocial and non-medical issues; confers with the PCP and refers patients to other Medical Home team members as appropriate or available, such as Social Work, Behavioral Health or Community Resource Specialists; using a warm handoff whenever possible.

- Coordinates care transitions across the health care delivery system including visits to specialists, visits to the Emergency Department or Urgent Care, admissions to inpatient and extended care facilities; and transitions to different models of care, such as long-term care or hospice.

- Contacts patients / families within 3 business days after discharge from a hospital admission, emergency room visit, or skilled nursing facility.
- Uses standard protocols to review patient understanding of discharge plan and medications
- Assesses patient and family self-management resources post-discharge.
- Assures that patient is seen in the primary care office within a timely manner after discharge.

- Completely, accurately and appropriately documents all of the above in the medical record.

- Proactively communicates with all Medical Home team members in a structured way
- Actively participates in daily huddles with Provider - Medical Assistant teams
- Actively participates in practice staff meetings

- Acts as a resource to other clinical staff in the practice.
- Participates as faculty for Skills Day and Clinical Redesign Training
- Participates in Process Improvement (PI) initiatives across the organization
- Demonstrates a strong understanding of the Virginia Mason Production System and the relevance to clinical redesign and the Patient Centered Medical Home

Professional Development
- Meets continuing education requirements to maintain licensure in Massachusetts.
- Pursues continuing education opportunities in chronic disease management and care coordination.


Job Qualifications; Brief description of the minimum qualifications for the job.
Skills: (Specific learned activity gained through training, e.g., typing, presentation skills, computer skills; e.g. Excel; CPR,ACLS)

- Excellent critical thinking skills.
- Strong assessment and problem solving skills.
- Strong interpersonal skills.
- Ability to work independently with minimal supervision.
- Goal oriented and accountable.
- Demonstrated organizational skills.
- Demonstrated ability to work in a complex setting.
- Must be able to work in a fast paced environment and demonstrate performance agility in a continuously changing environment.
- Ability to work in medical team based environment.
- Strong oral and written communication skills.
- Demonstrates appropriate communication skills for the patient population served.
- Good computer skills.
- Ability to quickly demonstrate competency in various software applications.

- Required: Minimum of 3 years nursing experience.
- Preferred: Primary care, home health, extended care, case management or care coordination experience preferred.

Education/Degree requirements:
- Required: Completion of an accredited Nursing degree program
- Preferred: Bachelor of Science in Nursing (BSN) strongly preferred.

Licensure, Certifications, or Registration:
- Required: RN
- Preferred: BSN strongly preferred

It is the policy of North Shore Medical Center and North Shore Physicians Group to affirmatively implement equal opportunity to all qualified candidates and existing employees without regard to race, religion, color, national origin, sex, age, ancestry, disability, Veterans of the Vietnam Era status; or any other basis that would be in violation of any applicable ordinance or law. All aspects of employment including recruitment, selection, hiring, training, transfer, promotion, termination, compensation and benefits.

Why North Shore Physicians Group?

You’ll practice at the leading edge of patient-focused medicine in one of New England’s most scenic and historic locations. And you’ll make a difference every single day. Make your move to NSPG. We’re one team, with one focus. Join us.

With NSPG you’ll experience:

Excellent quality of life

The North Shore area offers:

  • Communities with varied and rich histories and convenient access to museums, art, restaurants and shops.
  • Natural beauty, handsome architecture and vivid history — only 15 miles north of Boston.
  • 30 miles of gorgeous rocky coastline with breathtaking beaches and harbors.
  • World-class sailing and close proximity to the mountains and picturesque New England.
  • Easy access to a multitude of universities, colleges, and public and private schools.

Clinical excellence

  • Our practices are certified Level 3 NCQA Patient-Centered Medical Homes.
  • For the fifth year in a row, North Shore Medical Center has been ranked a top regional hospital in Boston and Massachusetts by U.S. News & World Report.
  • Our affiliate, Massachusetts General Hospital, is one of U.S. News & World Report’s top three Honor Roll hospitals in America.
  • NSPG and NSMC use the Epic EMR that integrates patient care through the Partners HealthCare System, including Massachusetts General Hospital and Brigham and Women’s Hospital.

Career advancement

  • Grow, learn and develop new practice innovations.
  • Continue your medical education.
  • Make academic connections and explore teaching opportunities.
  • Explore leadership opportunities.
  • Develop clinical and administrative career ladders.

A supportive practice environment

  • Collaborative professionals.
  • Patient-centered care model.
  • Leadership that listens and values your contributions and ideas.
  • Autonomy and respect for your skills and expertise.
  • Excellent salary and benefits.


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