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RN Complex Care Manager

Company: Boston Medical Center
Location: Boston
Posted on: January 27, 2023

Job Description:


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. Nurses or nurse practitioners in the position will work in one of 3 programs: Primary Care-based Complex Care Management, Readmissions Care Team, or ED-based Complex Care Management. Nurses or nurse practitioners in all programs will collaborate closely with one another in the care of shared patients. Nurses or nurse practitioners will be designated to one of three clinical sites depending on the specific program he/she is a part of: Primary Care Practice, Emergency Department (ED), or Inpatient.

Key Functions/Responsibilities:

  • 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.
        • Delegates assignments to Community Health Workers and/or Patient Navigators or Social Workers and follows up on completion. Manages staff performance through the following:
          • Tracks individual performance metrics
          • Provides one-on-one supervision to each team member on a regular basis
          • Consistently available for timely consult regarding patient matters during business hours
          • Develops on-boarding curriculum in collaboration with Medical Director
          • Facilitates access to appropriate training and educational resources
          • Facilitates access to appropriate supportive and psychosocial resources
          • First point of contact for corrective/disciplinary matters as needed.
          • 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 work flow standards
          • Maintains HIPAA standards and confidentiality of protected health information.
          • Adheres to departmental/organizational policies and procedures.
          • Care Manager will work full-time at the clinical site of care
            Other duties as assigned


            • AD or BS in Nursing
            • BS or Masters in Nursing


              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
                Certification or Conditions of Employment:

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

Keywords: Boston Medical Center, Boston , RN Complex Care Manager, Healthcare , Boston, Massachusetts

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