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North Shore Community Health Primary Care Team Nurse Care Manager in Salem, Massachusetts

Primary Care Team Nurse Care Manager

Salem, MA (

Job Type



Opportunity Overview

North Shore Community Health (NSCH) is an industry leader in exceptional delivery of community healthcare. The Primary Care Team Nurse Care Manager (PC team RN CM) is a registered nurse whose primary responsibility is to manage a panel of patients on an assigned primary care team who are identified for care management. Working collaboratively with the primary care team, specialty NSCH care teams, and community care providers, the PC team RN CM coordinates the overall health care utilization for NSCH’s most vulnerable patients.

The Organization

North Shore Community Health is a high performing community health organization that prides itself on being a compassionate community health center, serving its surrounding communities with comprehensive and culturally competent care.

NSCH offers comprehensive primary care, dental services, behavioral health care, care management, pharmacy, substance abuse disorder treatment, nurse care management, and insurance enrollment assistance services. NSCH has ten services sites: Gloucester, Peabody and Salem Family Health Centers; the school-based health centers at Salem High School and Peabody Veterans Memorial High School; and behavioral health only services at the Bentley Academy, Collins Middle School, Horace Mann School, Bates Elementary School, and the Peabody Learning Academy. NSCH offers competitive benefit plans and as a community-based safety net healthcare provider, NSCH welcomes staff who mirror the diversity of our communities and continues on its path to furthering its commitment to being an anti-racist organization.


North Shore Community Health’s mission is to build healthy communities by providing exceptional care to all.


Healthy People | Vibrant Communities



We take our responsibility to ourselves, each other, and the NSCH Community very seriously. We understand our individual roles, and positions of power with respect to how others perceive our roles and actions. We hold ourselves accountable when we make mistakes–acknowledging the error, owning it, taking corrective actions, and moving forward. We follow through on what we commit or resolve to do.


Integrity is the foundation of healthy relationships. We are committed to the highest ethical standards: honesty, fairness, respectfulness, and trustworthiness. We are honorable and respectful in dealings with others, and we strive to deal honestly, fairly and in a respectful, ethical, and trustworthy manner when in agreement or disagreement.


Empathy is a deep appreciation for another’s situation and point of view, which is the basis for the golden rule and our intrinsic sense of justice. We strive to bring empathy into our interactions with each other and with our patients.


We see courage as the strength of character to stand up for our convictions and belief system. To have courage is to have the fortitude to take risks and to extend one’s behaviors, actions, and thoughts beyond one’s comfort zone. We appreciate that courage is often required to compromise. Courage is a state of mind to face adverse, difficult, and challenging situations with confidence and positive energy.


NSCH holds its patients in the highest regard. We provide care that is respectful of and responsive to individual patient needs and values. We take the time to listen to concerns, understand what is important, and provide appropriate solutions and care. We do this through coordination and integration of care, collaboration, and teamwork.


NSCH is committed to the health and well-being of its community, patients, and staff. We demonstrate this commitment by constantly striving to align our actions with our mission, vision, and values.

EEO Statement:

We, North Shore Community Health (NSCH), are an equal employment opportunity employer. Our goal is to have a diverse workforce representative of all people, at all job levels, in the organization. We do not and will not make any personnel decisions (like recruiting, hiring, job assignments, and promotions) based on age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity, gender expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law.


  • Communicate with members of patient’s care team outside of the health center as needed, which includes specialists or visiting nurses, to help with coordination of care.

  • Serve as a liaison between NSCH and other care management programs and community-based organizations.

  • In collaboration with CHWs, ensure patient access to local community resources and help link care teams/patients with the appropriate resources.

  • Connect primary care team patients with needed behavioral health services, flexible services, Community Partners, respite care and other services.

  • Guide care team in accessing durable medical equipment, health services, and other community-based social services for patients.

  • Provide care coordination, facilitate care transitions, support the completion of referrals, and/or provide and confirm appropriate follow-up with care providers both within NSCH and with collaborating community care providers.

  • Oversee hospital and emergency department discharge workflows for patients on assigned panel.

  • Engage patients at their homes or other locations where the member may be located.

  • Meet patients while they are in the hospital, when appropriate, to provide education and support around the discharge process and transition members into care management.

  • Collaborate with specialty nursing care teams to connect patients with Hep C/HIV care, substance use disorder treatment, chronic disease/diabetes care, and anticoagulation management.

  • Perform job duties of the PC Team RN as needed, which include:

  • Collaborate and communicate with team primary care providers and other care team members to ensure quality and continuity of patient care on the primary care team

  • Participate and coordinate team huddles

  • Manage clinically related phone calls for the team including but not limited to: triage of same day appointments, abnormal labs, medication questions, and hospital discharges

  • Review refill requests from pharmacy and patients based on medication refill protocol; Reconcile patient medication lists and attach pertinent information necessary for provider to authorize the refill

  • Complete patient forms to the furthest extent possible, including prior authorization forms, request for VNA services, etc.

  • Assess and evaluate patient care needs

  • Analyze and interpret data and make informed judgments related to patient care.

  • Evaluate outcomes of basic nursing interventions and initiate changes in care plans.

  • Perform nursing interventions

  • Administer immunizations and medications and perform other procedures as needed, including but not limited to: EKGs, suture removals, wound dressing changes, PPD application and interpretation, and blood pressure checks.

  • Perform nurse visits independently and within the registered nurse scope of practice as outlined by the Massachusetts Board of Nursing.

  • Delegates activities to a non-nurse (i.e., medical assistant) within the parameters outlined by the Massachusetts Board of Nursing

  • Adheres to productivity goals such as those around panel size, patient engagement, and nurse visits.

  • Maintain accurate and timely documentation of all nursing care and patient communication, including phone notes, nursing visit notes and immunization or medication administration documentation, in accordance with NSCH policies and protocols.

  • Complete documentation within the care management platform(s) as directed by manager.

  • Ensures patient quality and coding gaps are addressed and collaborates with team to help meet population health/quality goals.

  • Provide coverage at any of the NSCH clinical sites as needed.

  • Performs additional duties to fulfill NSCH's mission, as assigned.


  • College degree from an accredited school of nursing with current license to practice as an RN in the Commonwealth of Massachusetts.

  • Current CPR certification.

  • Experience working as an RN in a community health center or related setting strongly preferred.

  • Ability to function effectively both as a leader, and a member of a team as well as a proven ability to work independently.

  • Ability to work in a culturally-diverse environment.

  • Excellent communication and interpersonal skills.

  • Excellent problem-solving skills.

  • Maintains high level of customer service with both patients and coworkers.

  • Possesses strong critical thinking skills and ability to prioritize and address many competing demands.

  • Must be able to recognize, and respond quickly to changes in patient and/or unit conditions.

  • Spanish/Portuguese language skills are a plus.

  • Experience with electronic health record, and strong computer skills required.

  • Sensitivity/skill in working with patients with complex medical, psychosocial and socioeconomic circumstances such as patients with significant mental illness, homelessness, poverty and substance use disorders.

  • Position will be hybrid remote/on-site, based at Salem Family Health Center. Ability to travel to other NSCH sites for meetings and periodic clinical coverage is required.

As a health center, NSCH expects all employees to receive all required vaccinations and health screenings each year. Moreover, as a condition of employment, all employees are expected to be vaccinated against COVID19, including providing proof of having received the COVID­19 vaccine, unless a religious or medical exception is granted. All prospective employees are required to be vaccinated before their first day of employment, and proof of vaccination record must be provided with pre­hire paperwork. To request an accommodation from the vaccine requirement or if you have any questions about this mandate, please contact the Human Resources Department ( .

At North Shore Community Health, we are dedicated to building a diverse workforce. Are you excited about this role but feel that your past experience does not align perfectly with every requirement in the job description? We encourage you to apply! Your skills may be suited for this or other roles here at North Shore Community Health

Living on the North Shore

With facilities in Salem, Peabody, and Gloucester, NSCH offers access to New England’s Coastal charm, while being just thirty minutes outside of Boston. The North Shore is connected to the city via the Rockport Commuter Rail line, which makes stops in Salem and Gloucester. The North Shore has plenty to offer, with a rich history and thriving cultural scene.

For Information Please Contact:

Talent Acquisition Department

North Shore Community Health