Complex Care Manager RN

Overview

RN Care manager responsible for working with Complex Care Team and Primary Care Providers to stabilize and support highest risk "Top 5%" Medicaid patients;
Also, supports ongoing relationship with site providers.

Position: Complex Care Manager RN

Department: Population Health Care Management

Schedule: Full Time

Format: Hybrid

Compensation: will be based on a salary/incentive plan.

ESSENTIAL DUTIES/RESPONSIBILITIES

• Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors, local clinical site leaders, and health plan colleagues
• Execute core care management duties:
• Comprehensive assessment: bio-psycho-social-spiritual
• Collaborate with patient and care team to develop patient-centered care plan, with 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
• Assessment of goal completion, with transition of patient to inactive or graduated status as appropriate
• Use 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
• Knowledge of common chronic medical conditions and ability to:
• Educate the patient on their medications and build self-management skills
• Use motivational interviewing to promote behavioral change
• Assess, triage, and rapidly respond to clinical changes that could lead to emergency services if not intervened upon
• Delegate assignments to Community Health Workers and/or Patient Navigators or Social Workers and follow up on completion
• Track individual performance metrics
• Be consistently available for timely consult regarding patient matters during business hours
• Participate in local site operations, including team meetings and curbsides with care team members
• Participate in planning and growth of the program with relevant stakeholders to respond to evolving Mass Health ACO needs
• Facilitate interdisciplinary consultation on patient s behalf through rounds, team meetings, and clinical reviews
• Comply with established metrics for performance and adhere to documentation and workflow standards
• Maintain HIPAA standards and confidentiality of protected health information
• Adhere to departmental/organizational policies and procedures
• Care Managers work full-time in a hybrid format, splitting time between remote work, the clinical site of care, and in patients  homes/community

• ED and inpatient visits
• Assessment completion (initial, post-discharge, etc.)
• Total medical expense
• Patient satisfaction
• Clinical outcomes
• Provider satisfaction
• Avoidable admissions; reduction in readmission

Job Requirements

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

• A minimum of two years of clinical experience required, with care management experience preferred
• Preferred experience:
• Experience working with vulnerable patient populations
• Home care, primary care, and/or care management nursing experience
• Clinical experience with patients who have multiple complex health issues, including unhoused persons
• Experience working in, or collaborating with, shelter systems
• Motivational Interviewing

• Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts
• AND/OR
• Completed an accredited educational program for Nurse Practitioners

• Excellent interpersonal skills and ability to work collaboratively
• Self-management skills, including ability to prioritize and set patient-centered goals
• Excellent written and verbal communication
• Able to maintain professional boundaries
• Ability to work with diverse safety-net populations
• Skilled at engaging difficult-to-engage patients—build rapport and trust
• Creative problem solver
• Ability to adapt to changes in healthcare delivery at…