As an integral member of the care management team the RN and/or Behavioral Health (BH) Care Manager (CM) will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic conditions, many of whom also face multiple barriers in their lives which makes it difficult for them to achieve the self-care required to improve their health and well-being. This position requires flexibility and may vary from day-to-day to meet members where they are. The Float Pool Position is hybrid though primarily remote and will cover care management vacancies at C3-affiliated FQHCs and affiliated provider groups. Job Responsibilities: Conducts Comprehensive Clinical Assessments Assures that medication reconciliation is complete depending on MA state licensure. The RN CM will complete the medication reconciliation and may include a pharmacist and/or primary care Team. BH CM will facilitate medication reconciliation with pharmacist and/or primary care team Engages members and caregivers in active care planning with a focus on, medical, behavioral, social, and member-centered care needs. Coaches and guides member/representatives to meet bio/psycho/social care goals. Provide care coordination, which may include but is not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up May be required to meet members while they are inpatient to provide education and support about the discharge process and transition the member into care management Assesses the members knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support based on the members needs and preferences. Connects members with primary care, behavioral health, flexible services, Community Partners, respite, and other community-based social services as indicated and appropriate. In collaboration with Community Health Workers creates and maintain a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services. Participates in the integrated care team meetings and rounds as required Maintain accurate, timely documentation in electronic systems including health center EHRs Provides coverage for team members who are out of office Other duties as assigned Required Skills: 3-5 years of nursing experience, preferably in-home health, ambulatory care, community public health, case/care management, coordinating care across multiple settings and with multiple providers or 2-3 years of Inpatient or Community Social Work experience providing patient-centered outreach, behavioral health services, needs assessment and support Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Pharmacists, Nurses, Community Health Workers, and other healthcare teams Ability to flexibly utilize clinical expertise to solve complex problems Experience working with patients with chronic and behavioral health needs Must be flexible and adaptable to change Demonstrate the ability to work independently Must demonstrate excellent interpersonal communication skills Qualifications: Current, active MA Registered Nurse license or Licensed Clinical Social Worker (LCSW or LICSW), or Licensed Mental Health Counselor (LMHC) Associate degree in Nursing; Bachelors Degree in Nursing preferred or masters degree in Psychology, Social Work, or related field Case Management Certification (CCM, ANCC RN-BC) preferred though not required