Transitions of Care RN Care Manager

Transition Of Care Nurse Manager

Across the country, governments, employers, and American families have struggled in the face of rising healthcare costs. Efforts historically have targeted narrow programs and patient populations, and while many have succeeded, healthcare costs continue to rise. It's time to take a radically different approach. A new approach involves putting the patient at the center with the goals of improving value and providing better outcomes at lower cost for patients.

The Population Health Management (PHM) department at Mass General Brigham is charged with the challenge to drive better value for patients across Mass General Brigham. To achieve its goals, PHM leverages financial and clinical data to examine opportunities, designs and delivers innovative care models using product development and design thinking disciplines, and leverages problem solving, teamwork, and leadership skills to drive ongoing improvement.

As an integral member of the Population Health Management Operations team, The Transition of Care Nurse Care Manager provides episodic care management for Medicare Shared Savings Program (MSSP) and Medicaid ACO patients from inpatient admission to home. This includes follow up phone calls after discharge, medication reconciliation, and ensuring patient has appropriate follow up appointments scheduled as well as documenting and ensuring all billing requirements are met prior to submitting TCM charges.

The Transition of Care Nurse Manager directly interfaces with patients (via phone), Primary Care physicians, pharmacists, care managers, and health care teams involved in patient care as well collaborating with PHM Clinical Operations leadership.

Primary Responsibilities:

• Manages episodic transitions of care for Medicare Risk and Medicaid risk patients from inpatient discharge to home as applicable.
• Demonstrates effective teamwork and collaboration with the primary care provider and the care team

Organizational Responsibilities:

• Demonstrates a positive attitude in dealing with patients, co-workers, and other health care providers and in addressing problems and/or crisis situations.
• Requires the ability to work independently as well as function effectively within a team-based model of care.
• Able to establish collegial relationships with physicians, office staff and health care providers in physician's offices, community agencies, hospitals, and other health care facilities.
• Functioning within the patient centered model of care, demonstrates a commitment to meeting the patient's needs and expectations.
• Functioning within the team-based model of care
• Demonstrates initiative and creativity to continuously improve services, work processes, and other activities that affect quality and utilization.
• Follows applicable policies and procedures for general safety, fire safety, infection control, attendance, punctuality, and appearance.
• Performs all duties as assigned.

Other

Duties and Responsibilities:

• Assumes accountability for professional growth and development.
• Acts as a role model for patients by practicing behaviors consistent with the program goals of health promotion and disease prevention.
• Identifies quality of care issues and reports the concerns to the appropriate person.
• Collects, prepares, and reports data as directed.
• Assists in preparation for external audits and surveys as applicable.

Qualifications:

• Required:
• Associate's Degree Nursing (ASN) or Bachelor's Degree Nursing (BSN).
• RN License for State of MA.
• 3+ years of experience in hospital, health plan or community case management or utilization management role.
• Care management or home care background.
• Managed Care or previous healthcare reimbursement knowledge.
• Preferred:
• Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
• Certification in Case Management (CCM) and/or other applicable professional certification preferred.
• Previous experience working in a post-acute setting such as LTAC, acute rehabilitation, skilled nursing facility, or homecare.
• Bedside nursing experience.

Additional Skills, Knowledge and Abilities:

• Excellent…