Complex Care Manager RN

The Complex Care Manager works with relevant stakeholders to identify and engage patients in care management with a focus on patient experience, improving health and reducing cost. This individual will direct and manage Community Health Workers and/or Patient Navigators in 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.

POSITION SUMMARY:

This position is Monday - Friday, 40 hours FTE, no weekends or holidays observed by BMC. Business hours, typically between 8:30 am - 5 pm. This position is a blended hybrid role, offering opportunities for both in person and remote work from home. Canidates must have a working vehicle and be able to travel independently. This role serves patients in the Brockton, Randolph, Raynham, Bridgewater, Easton and Quincy Communities. This position allows ~ 2 days per week working from home, ~ 3 days working in the community, practice site, patient home settings. The dress code is business casual.

The Complex Care Manager works with relevant stakeholders to identify and engage patients in care management with a focus on patient experience, improving health and reducing cost. This individual will direct and manage Community Health Workers and/or Patient Navigators in 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 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.

Compensation will be based on a salary/incentive plan.

Position: Complex Care Manager RN

Department: Signature Nurses

Schedule: 40 Hours (Days)

ESSENTIAL RESPONSIBILITIES / DUTIES:

• 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 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 and/or Social Workers.

• 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 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 Manager must be available to work at the clinic site on assigned practice days in person.

Metrics:

• ED and inpatient visits

• Total medical expense

• Patient satisfaction

• Clinical outcomes

• Provider satisfaction

• Avoidable admissions

Other duties as assigned

JOB REQUIREMENTS:'

Education:

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

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED :

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

Experience:

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

Preferred experience:

• Experience working with vulnerable patient populations

• Home care or clinic

• Motivational interviewing

• Clinical experience working with patients with multiple complex health issues

• Care management

KNOWLEDGE AND SKILLS:

• 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 population

• Skilled at engaging difficult to engage patients—build rapport, trust

• Creative problem solver

• Ability to adapt to changes in healthcare delivery at 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 skill

Equal Opportunity Employer/Disabled/Veterans

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