LTSS - Registered Nurse at BMC HEALTH SYSTEM INC

Boston, Massachusetts, United States -

Full Time

Start Date

Immediate

Expiry Date

27 Dec, 25

Salary

0.0

Posted On

28 Sep, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Holistic Care, Care Management, Motivational Interviewing, Chronic Condition Support, Disease Management, Collaboration, Communication, Clinical Problem-Solving, EMR Proficiency, Organizational Skills, Behavioral Health Experience, Pediatric Experience, Care Coordination, Discharge Planning, Medication Compliance, Community Support

Industry

Medical Practices

Description

POSITION SUMMARY: LTSS Registered Nurse (RN) Boston Medical Center – Boston Allied Partners (BAP) About the Role As an LTSS Registered Nurse (RN), you’ll provide holistic, person-centered care management services for Boston Allied Partners (BAP) members. Our enrollees include individuals with chronic conditions, complex care needs, and those facing challenges such as homelessness, organ transplantation, or multiple clinical and behavioral health comorbidities. You’ll work side-by-side with a diverse care team—including physicians, behavioral health specialists, pharmacists, community partners, and state agencies—to deliver care that addresses both the medical and social drivers of health. Your role is essential in helping members set and achieve goals, improve their quality of life, and reduce avoidable hospitalizations. Key Responsibilities Complete comprehensive and condition-specific assessments for enrollees upon admission and at least annually. Evaluate enrollee needs for complex care management, chronic condition support, and disease management programs. Collaborate with Care Coordinators to design individualized, person-centered care plans focused on enrollee goals and objectives. Identify and address barriers to self-management, ensuring members access benefits, resources, and community supports. Use motivational interviewing techniques to engage enrollees in health promotion, disease management, and preventive care. Leverage real-time EMR data and utilization reports to promote medication compliance and develop action plans with providers. Monitor outcomes and adjust care plans to ensure effectiveness. Educate members using evidence-based guidelines and accessible, standardized educational materials. Support transitions of care with pre-admission assessments, post-discharge follow-ups, medication reviews, and coordination of home health, transportation, or durable medical equipment needs. Conduct face-to-face visits in homes, shelters, medical offices, or community settings, in addition to phone and telehealth outreach. Facilitate multidisciplinary consultations, participate in team rounds, and contribute to clinical reviews. Provide mentoring and training to staff and consult with colleagues as needed. Document all activities in real time using BAP’s care management platforms, ensuring accuracy, timeliness, and compliance with contractual requirements. Maintain HIPAA standards, contractual knowledge, and organizational policies. Qualifications Education: Current RN license (MA) BSN preferred; ASN with relevant work experience considered Experience: 3+ years in home health or managed care settings 3+ years of clinical experience with members managing multiple chronic or complex health conditions 2+ years in care management, care coordination, or discharge planning Behavioral Health and/or Pediatric experience strongly preferred Preferred Skills & Background: Experience working with Medicaid recipients and community-based services Familiarity with Epic, eHana, CCMS, SFTP, or other EHR/healthcare databases CCM certification Core Competencies: Strong motivational interviewing, coaching, and communication skills Effective collaboration with providers and multidisciplinary teams Ability to work in a fast-paced environment and manage multiple priorities Proficiency in Microsoft Office, EMRs, and care management systems Strong organizational and clinical problem-solving skills Working Conditions Regular and reliable attendance is required. Work may be performed in-office, home office, or community settings. Face-to-face visits will occur in member homes, shelters, physician offices, hospitals, or other agreed-upon locations. Limited physical effort and exposure to physical risk. Reliable transportation required for community face-to-face visits. Equal Opportunity Employer/Disabled/Veterans According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or “apps” job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment. Working at Boston Medical Center is more than a job. It’s a chance to make a difference as part of our mission to provide exceptional and equitable care to all. As a nationally-recognized leader in health equity, nursing, initiatives to combat climate change, and many other areas, BMC is dedicated to improving the health of our community in Boston and beyond. BMC’s mission to provide exceptional care without exception extends to our employees, and we have been recognized as a top employer and best place to work. A strong sense of teamwork and support for our staff are the bedrock of BMC, as we know that we can only provide exceptional care to patients when our staff are cared for too. Boston Medical Center is an equal employment/affirmative action employer. We ensure equal employment opportunities for all, without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic. If you need accommodation for any part of the application process because of a medical condition or disability, please send an e-mail to Talentacquisition@bmc.org or call 617-638-8582 to let us know the nature of your request. Boston Medical Center participates in the Electronic Employment Verification Program. As an E-Verify employer, prospective employees of BMC must complete a background check before beginning their employment at the hospital. BMC requires all staff to be vaccinated against COVID-19 and flu, as well as receive a booster dose of the COVID-19 vaccine. According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or “apps” job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment. To avoid becoming a victim of an employment offer scam, please follow these tips from the FTC: FTC Tips

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Responsibilities

As an LTSS Registered Nurse, you will provide holistic, person-centered care management services for members with chronic conditions and complex care needs. You will collaborate with a diverse care team to design individualized care plans and support members in achieving their health goals.