POSITION SUMMARY:

The Complex Care Manager works with relevant stakeholders to identify and engage patients in care management, focusing on patient experience, improving health, and reducing cost. This individual will collaborate with Community Wellness Advocates (also known as Community Health Workers) in the completion of assigned patient care related tasks. The individual is responsible for working with patients to identify strengths and barriers and to develop an individualized, patient-centered care plan. Excellent interpersonal skills, clinical expertise in conditions prevalent in the Medicaid population (Substance Use Disorder, Serious Mental Illness, Congestive Heart Failure [CHF ], etc.), patient engagement skills, and the ability to work independently and collaboratively are key requirements of the job.

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 opportunities to care for patients, including during primary care visits, during ED or IP visits, out in the community, or on the phone. Nurses will be paired with Community Wellness Advocates on a shared patient panel, where the CWA will focus on social determinants of health.

Position:Complex Care Manager RN

Department: Population Health, Care Management

Schedule: Full Time, 40 hours, Mon-Fri, Days.

Format: Hybrid

ESSENTIAL DUTIES/RESPONSIBILITIES:

Key Functions/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

• 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;

  • Assessment of goal completion, with transition of patient to inactive or graduated status as appropriate.

• Uses 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 medical 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.

• Delegates assignments to Community Health Workers and/or Patient Navigators or Social Workers and follows up on completion.

• Tracks individual performance metrics

• Consistently available for timely consult regarding patient matters during business hours

• Participates in local site operations, including team meetings, curbsides with care team members, etc.

• Actively participates in planning and growth of the program with relevant stakeholders as needed to respond to the evolving needs of MassHealth 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 workflow standards

• Maintains HIPAA standards and confidentiality of protected health information.

• Adheres to departmental/organizational policies and procedures.

• Care Managers will work full-time, in a hybrid format, splitting their time between remote, the clinical site of care, and in patient's homes/community.

Metrics:

• ED and inpatient visits

• Total medical expense

• Patient satisfaction

• Clinical outcomes

• Provider satisfaction

• Avoidable admissions

JOB REQUIREMENTS

EDUCATION:

• AD or BS in Nursing

Preferred/Desirable:

• BS in Nursing

EXPERIENCE:

• A minimum of two years of clinical experience is preferred, with care management experience preferred

• Must have a valid Driver's License and access to reliable transportation

Preferred experience:

• Experience working with vulnerable patient populations

• Home care, primary care, and/or care management nursing experience

• Clinical experience working with patients with multiple complex health issues, including persons experiencing homelessness

• Experience working in, or collaborating with, shelter systems

• Motivational Interviewing

CERTIFICATION OR CONDITIONS OF EMPLOYMENT:

• Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts.

COMPETENCIES, SKILLS AND ATTRIBUTES:

• Excellent interpersonal skills and ability to work collaboratively

• Self-management skills, including the ability to prioritize and set patient-centered goals

• Excellent written and verbal communication

• Able to maintain professional boundaries

• Ability to work with a diverse, safety-net population

• Skilled at engaging difficult-to-engage patients-building rapport, and trust

• Creative problem solver

• Ability to adapt to changes in healthcare delivery at the local and systems level

• Extensive knowledge of healthcare systems and community resources

• Ability to leverage systems and resources for improved patient outcomes

• Strong organizational and time management skills

Equal Opportunity Employer/Disabled/Veterans