Nurse Care Manager

When you join the growing BILH team, you’re not just taking a job, you’re making a difference in people’s lives. The Care Manager, RN provides care management services to the BILHPN primary care physicians focusing on at risk, high cost, and chronic/complex condition patient populations. Collaborates with the primary care team to develop care plans on their at-risk patient population through care coordination, condition management education and community resource support.

Responsibilities include working with physicians, patients, families, and the multidisciplinary team in all settings to optimize quality and efficient outcomes; and decrease total medical expenses. The Care Manager, RN assesses, plans, implements, coordinates, monitors and evaluates options and services to meet the individual patient needs. This role is a hybrid position. The Care Manager works closely with the primary care provider and patient to develop collaborative care plans to improve self-management of chronic conditions utilizing evidence-based best practice standards. The Care Manager, RN builds relationships with the patient through use of motivational interviewing techniques to promote engagement in healthy behaviour.

Working with the healthcare team, the Care Manager, RN monitors appropriate utilization of healthcare resources, promotes quality and efficiency by developing and implementing a patient centred care plan. The RN Care Manager is accountable for ensuring efficient and professional services for patients and families that are designed to promote and enhance their physical and psychological functioning with attention to the social and emotional impact of illness and disability. The Care Manager, RN upholds the current standards of professional case management practice, and reports to the Manager of Care Management.

The Care Manager, RN supports the primary/specialty care physicians in population health management by focusing care coordination attention on the at-risk population driving utilization and costs to improve efficiency, quality and patient satisfaction. Engages physician and practice team in proactive patient management by addressing medical/psychosocial/functional health care needs, follow-up, and referrals. Utilises a designated patient roster reports to review at risk population with providers to prioritise program enrollment, care planning, addressing prognosis and potential palliative/hospice care referrals.

Offers and coordinates free care consultation to patient/caregiver telephonically, to reinforce condition management, provide education and community resource navigation. Develops comprehensive care plans in collaboration with patient, physician and health care team based on evidence-based best practice for chronic condition management. Creates a patient-centred care plan that addresses problems/barriers and develops action plan relevant to obstacles in chronic condition management. Refers patients to appropriate community resources and support programmes.

Serves as the central resource for the physicians and practice team for the Medicare ACO population functioning as navigator, coach, and condition manager for the targeted patient population. Collaborates with patients to facilitate healthy behaviours. Utilises coaching to foster healthy lifestyle management. Helps patients to learn strategies and skills designed to stabilise symptoms and prevent condition progression. Aims to improve the individual’s overall quality of life by supporting treatment goals, empowering them to be advocates for themselves and assisting them to obtain benefits, access to health care and connect to social and community services.

Advocates for patients and families, responds to and facilitates resolution of patient questions and concerns. Reviews at risk patients with providers to understand drivers of cost, current treatment plan, future course and prognosis. Ensures advance directives and appropriate referrals are addressed, such as palliative/hospice, and makes recommendations for cost reduction alternatives whenever appropriate. Seizes opportunities to reduce gaps in care by making recommendations for efficiency, quality and cost improvement. Understands organizational goals and accountability towards maximising organisation performance.

Conducts formal reassessments at prescribed intervals and whenever there is a significant change in the patient’s health, abilities, living situation, and family involvement. Works collaboratively with other professionals to maintain a team oriented approach to care management and incorporates shared decision making in all patient interactions.

The Care Manager, RN interfaces daily with patients, families, assigned physicians, the health care team, community agencies, vendors, and health system staff to ensure efficient, quality care delivery. Reviews at risk cases with Medical Director and physicians in a concise, effective, professional manner. Addresses medical/psychosocial concerns and makes recommendations to improve efficiency and quality care. Serves as an educational/informational resource to physicians, provider care team, and patient/family regarding inpatient/outpatient resources.

Participates in care team huddles by communicating important information on at risk cases with interdisciplinary team. Documents in the case management record clear, concise, timely notes that address patient problems, barriers, goals, support systems, advance directives, transition plan and case management interventions to improve efficiency, quality and reduce cost. Assists with the 3 day Waiver Program during regular business hours. Attends weekly interdisciplinary meetings to improve the coordination of care and assist with discharge planning.

The Care Manager, RN strives to provide a quality patient and provider experience while working in collaboration with the patient/family and primary/specialty care physician team. Coordinates care to maximise the value of services delivered to patients to improve health care outcomes. Incorporates shared decision making in all aspects of patient care interactions. Promotes patient autonomy and self-management at every encounter. Creates a culturally sensitive care plan while utilising health literacy and language appropriate patient education materials to promote engagement in plan.

The RN care manager is responsible for timely reporting of quality events in the inpatient/outpatient care setting to ensure continuous monitoring for quality improvement. Refers quality/risk management cases to Manager, Medical Director and reports events per BILHPN policies, regulatory and/or health plan requirements. Identifies opportunities to improve patient adherence with ACO quality measures. Reports and follows up on patient complaints to ensure quality care and patient satisfaction. Participates in quality improvement projects and other educational sessions offered by the employer to promote continuous learning.

Minimum Qualifications: BSN preferred, experience in care management and health care system considered in lieu of degree. Active, unrestricted Massachusetts Registered Nurse License required. Certification in Case Management (CCM) preferred. NH Licensure or reciprocity desirable.

Experience: Case management and nursing experience preferred. Experience working in Skill Nursing Facilities with knowledge of Medicare guidelines. Experience with coaching while working with the chronic, complex population in a physician management service organisation is desirable. Experience with Commercial Insurance quality gap closure and Medicare population in managed care, medical home or integrated case management environment is preferred. Must be proficient in computer skills, internet, information technology and electronic medical record use.

Skills, Knowledge & Abilities: Strong development, analytic and systems building skills. Must be facile with physician relations, developing systems and procedures, developing and operating a capitated managed care infrastructure, continuous quality improvement, human resources management and fiscal management. Excellent written and verbal communication skills. Must have a professional demeanour and the ability to deal with physicians, senior management, and local industry. Capable of serving as a spokesperson and leader of the integration process and communicate the vision to others in the community. A well-defined style that demonstrates confidence, maturity, self-motivation, high energy, collaboration, high intellect and leadership qualities. Excellent interpersonal skills, be an appropriate risk taker, politically savvy, diplomatic, able to deal with ambiguity, flexible, organised, results oriented, a hard worker, a quick study, good with details and have integrity. Ability to function as a facilitator who can further the organisation to serve the evolving Network.

As a health care organisation, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment.