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Chronic Nurse Case Manager - Adult Medicine

Chronic Nurse Case Manager - Adult Medicine

Requisition ID 
# of Openings 
425 North Lake Avenue
Job Locations 
Posted Date 
Care Management
Job Code 

More information about this job


Glob Top Places to WOrk 17


Reliant Medical Group is seeking a Nurse Case Manager to join our excited and innovative organization!


Full Time: 40 hours per week 8:30am-5:00pm

Adult Medicine


Manages all aspects of patient centered care for a panel of patients with identified needs, while working as part of a health care team (Providers, Nurses, Social Workers, Patients, Family, Caregivers, etc).


  • Provides comprehensive case management and care coordination for a panel of patients with identified needs. “Coaches” (rather than “teaches”) patients to improve their health behavior to attain health-related goals. 
  • Completes a comprehensive patient needs assessment for each patient.
  • Develops and communicates (with patient, caregiver and primary care physician/health care team) a comprehensive care plan based on evidence-based best practice for chronic illness.
  • Proactively manages and follows-up (using home visits and telephone calls) according to care plan.
  • Manages and coordinates all transitions of patient’s care. Communicates care plan to all providers in all settings of care (emergency department (ED), hospital, rehabilitation facility, nursing home, home care and specialist). Ensures that relevant providers receive timely clinical data for care treatment decisions in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care, and specialty care).
  • Directs caregiver support, including ad hoc telephone advice.
  • Facilitates patient and caregiver access to community resources relevant to patient needs, including referrals to transportation programs, Meals on Wheels, senior centers, chore services, etc.
  • Incorporates self-care and shared decision making in all aspects of patient care.
  • Complies with health and safety requirements and with regulatory agencies such as DPH, etc. 
  • Complies with established departmental policies, procedures, and objectives.
  • Enhances professional growth and development through educational programs, seminars, etc. 
  • Attends a variety of meetings, conferences, and seminars as required or directed.
  • Performs other similar and related duties as required or directed.


  • Graduate from an accredited school of nursing.
  • Active, unrestricted licensure as a Registered Nurse in Massachusetts; current Massachusetts driver’s license.
  • A minimum of five years nursing experience, preferable with adults
  • Excellent communication, interpersonal and organizational skills, with a flexible and creative approach to problem solving.
  • Works effectively both independently as well as a member of an interdisciplinary team.
  • Proficient in computer use, the Internet and health information technology.
  • EMR experience preferred.
  • Ability to travel to hospitals, skilled nursing facilities, patient’s homes, and other sites where patients receive care as needed.

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