ACO Nurse Care Manager

Caring Health Center•Springfield, MA

8d•Hybrid

About The Position

The Nurse Care Manager provides complex care management, connecting members with appropriate social services and promoting self-management of their behavioral and medical needs. The Nurse Care manager is a key member of an interdisciplinary team in the development and implementation of care plans to enhance the member’s overall health and to achieve appropriate utilization of services. They will also assess plans, implement, coordinate, monitor, and evaluate care plans, services, and outcomes to maximize the health of the member.

Requirements

Licensed Practical Nurse (LPN) with Care Management experience, Associate degree in Nursing (ASN) or Bachelor’s degree in Nursing, BSN (preferred)
Current, active MA Nursing license
Minimum 2-5 years of nursing experience in community public health, case management, coordinating care across multiple settings, and with multiple providers is also recommended.
A valid driver's license and provision of a working vehicle.
Demonstrated success in working as part of a multi-disciplinary team, including communicating and working with Providers, Pharmacists, Social Workers, Community Health Workers, and other health care teams.
Experience within the ACOs member population preferred, including Medicare/Medicaid
Ability to flexibly utilize clinical expertise to solve complex problems.
Bi/multi-lingual preferred or experience with Language Translation Services
Experience working with patients with chronic and behavioral health needs.
Must be flexible and adaptable to change.
Demonstrate the ability to work independently with licensure support and oversight where applicable.
Must demonstrate excellent interpersonal communication skills.
Experience using appropriate technology, such as computers, for work-based communication.

Nice To Haves

Case Management Certification (CCM, ANCC RN-BC) preferred.
Familiarity with the MassHealth ACO program
Familiarity with Federally Qualified Health Centers

Responsibilities

Conducts Comprehensive Assessments
Ensures that medication reconciliation is complete. The Nurse CM will complete the medication reconciliation and may include a pharmacist and/or primary care team.
Engages members and caregivers in active care planning with a focus on medical, behavioral, social, and member-centered care needs. Coaches and guides members/representatives to meet bio/psycho/social goals.
Provide care coordination, which may include, but not limited to, facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.
May be required to meet members while they are inpatient to provide education and support about the discharge process and transition members into care management.
May need to travel throughout the assigned area to engage members at their homes, at the health center, or other locations where the member may be located.
Assesses the member’s knowledge of their medical, behavioral health, and/or social conditions and provides education and self-management support, including symptom response plans based on the member’s needs and preferences.
Connects members with primary care, behavioral health, flexible services, Community Partner, respite, and other community-based social services as indicated and appropriate.
Participates in the integrated care team meetings and rounds as required.
Maintain accurate, timely documentation in the Electronic Health Records (EHRs)
Provides coverage for team members who are out of the office.
Other duties as assigned.