Complex Care Manager RN, Pop Health

Primary Care-based Complex Care Management:
The CCM team will be embedded in local primary care practices. The team will partner closely with PCPs, Integrated Behavioral Health Professionals, Pharmacists, and other local resources in the Primary Care Practice to develop multi-disciplinary care plans. Nurses will proactively seek out opportunities to care for patients, including during PC visits, during ED or IP visits, out in the community, or on the phone.

Nurses will be paired with Community Wellness Advocates who will partner with nurses on a shared patient panel, and will focus on social determinants of health.

Complex Care Manager RN

Pop Health

Full Time, 40 hours a week Monday through Friday business hours. No weekends, no major holidays observed by BMC

Compensation will be based on a salary/incentive plan.

• Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leaders
• Ability to execute core care management duties:
  • Comprehensive assessment: bio-psycho-social-spiritual
  • Collaboration with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning (HCP, MOLST)
  • Implementation of care plan;
  • Collaboration with community partners, such as VNA agencies, caregiver programs (PCA, ADH, AFC), DME providers and social service agencies;
    5) assessment of goal completion, with transition of patient to inactive or graduated status as appropriate.
• Uses motivational interviewing: reflective, empathetic language and open-ended questions to understand what the patient truly wants for him/herself beyond being healthy and staying out of the hospital
• Meet the patient where he/she is; observe the patient without intervention or judgment
• Has knowledge of common chronic medical conditions presented in the population served and is able to:
  • Educate the patient on their medication conditions and medications, and build their self-management skills;
  • Use motivational interviewing to promote behavioral change;
  • Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
  • Collaborates with Community Health Workers, Pharmacy team, and Social Workers and follows up on completion.
  • Meets regularly with leaders at the local clinical site (Primary Care, ED, inpatient), and care management supervisor, to triage program issues appropriately.
  • Participates in local site operations, including team meetings, curbsides with care team members, etc.
  • Actively participates in planning and growth of program with relevant stakeholders as needed, to respond to evolving needs of Mass Health ACO.
  • Facilitates interdisciplinary consultation on patient’s behalf through participation in rounds, team meetings and clinical reviews
  • Complies with established metrics for performance and adheres to documentation and work flow standards
  • Maintains HIPAA standards and confidentiality of protected health information.
  • Adheres to departmental/organizational policies and procedures.
  • Care Manager will work full-time at the clinical site of care

• ED and inpatient visits
• Total medical expense
• Patient satisfaction
• Clinical outcomes
• Provider satisfaction
• Avoidable admissions

• Nursing degree:
  Diploma, ASN or BSN (preferred), Ability to obtain BSN within 4 years required
• BS or Masters in Nursing preferred

• CCM Certification preferred
• Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts AND/OR…