LTSS - Registered Nurse

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

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