Care Manager, Transitions of Care, RN-Hybrid

Job Summary

It's an exciting time to join the Well Sense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

The Clinical Care Manager provides holistic care management services for members throughout the continuum of care by assessing the member clinically as well as member's readiness to make behavioral changes and actively participate in a care plan, establish goals and meet those goals. Wellsense Health Plan members may include those who have chronic conditions and complex care needs, including those considered to be the highest risk members those who are homeless, undergoing organ transplantation, have multiple clinical and behavioral co‑morbid conditions, and with special health care needs.

The clinician works collaboratively with a multidisciplinary team (both internal and external) including providers, our clinical vendor partners (pharmacy, etc.) and community/State agencies to increase patient knowledge, motivation, and compliance with treatment through targeted interventions that address the member's holistic needs from a medical and psychosocial/socioeconomic standpoint. Following this approach, the goal is to improve member health outcomes and decrease overall cost while improving the member's overall experience with the health care delivery system.

Utilizing both telephonic outreach and face‑to‑face member visits and through the use of assessments, real‑time data, motivational interviewing techniques and evidence‑based practices, the Clinical Care Manager engages with the member and the multidisciplinary team to develop an Individualized Care Plan (ICP) that emphasizes self‑management goals, care coordination, psychosocial, socioeconomic, and community‑based supports and ongoing monitoring and appropriate follow‑up. The Clinical Care Manager identifies and addresses barriers to optimal self‑management and works with the member, their support persons, and team to coordinate care throughout the health care continuum, assisting the member to access all available benefits and resources including family support and community resources, with a goal of promoting appropriate utilization of services at the appropriate level and site of care such as preventing ambulatory sensitive emergency department visits and inpatient admissions, avoiding readmissions, and encouraging the member to keep scheduled outpatient appointments to include preventive care visits.

The clinical care manager may meet members in their homes, shelters, provider offices, medical facilities, and at locations agreed upon with the member. Position requires approximately 50% or greater travel to conduct in‑person transitions‑of‑care member visits across Hampden and Worcester, or Suffolk counties. Mileage reimbursement is provided at the applicable IRS rate.

• Full‑time hybrid work
• Competitive salaries
• Excellent benefits

• Supports programs and clinical best practices with the objective of improving health outcomes, preventing hospital readmissions, improving member safety and reducing medical errors, and promoting health and wellness activities, where appropriate.
• Completes a transitional care management assessment and applicable condition specific assessments.
• Collaborate with hospitals to ensure a seamless transition of care upon admission and discharge to the community, and detail information sharing and collaboration between the Health Plan and the participating hospital.
• Coordinates member care transitions through pre‑admission assessments, post‑discharge assessment and follow‑up to ensure appointment is made with the PCP or Specialist; assessing for home health services, DME needs, and transportation issues; performing medication reconciliation; ensuring compliance with discharge plan, appointments and medication regimen.
• Uses available standardized educational materials in an appropriate reading level to educate members about their conditions.
• Monitors members' labs, tests results, appointments and other data in order to best coordinate care utilizing EMR…