RN Complex Care Manager
Company: Boston Medical Center
Location: Boston
Posted on: January 27, 2023
Job Description:
POSITION SUMMARY:
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
Qualifications:
Education:
- AD or BS in Nursing
Preferred/Desirable:
- BS or Masters in Nursing
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
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
Didn't find what you're looking for? Search again!
Loading more jobs...