Complex Care Manager RN, Pop Health, 40 Hours (Days)

BMC Software•Boston, MA

3d•$89,500 - $130,000•Onsite

About The Position

The Complex Care Management (CCM) team will be embedded in local primary care practices, partnering closely with Primary Care Physicians (PCPs), Integrated Behavioral Health Professionals, Pharmacists, and other local resources. The role involves proactively caring for patients through various touchpoints including PCP visits, ED or inpatient visits, community outreach, and phone consultations. Nurses will be paired with Community Wellness Advocates to focus on social determinants of health for a shared patient panel.

Requirements

Nursing degree: Diploma, ASN or BSN (preferred).
Ability to obtain BSN within 4 years required.
CCM Certification preferred.
Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts AND/OR Completed an accredited educational program for Nurse Practitioners.
A minimum of two years of clinical experience is preferred.
Care management experience preferred.
Experience working with vulnerable patient populations.
Home care or clinic experience.
Motivational interviewing experience.
Clinical experience working with patients with multiple complex health issues.
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 skills.

Nice To Haves

BS or Masters in Nursing preferred.
CCM Certification preferred.
Care management experience preferred.
Experience working with vulnerable patient populations.
Home care or clinic experience.
Motivational interviewing experience.
Clinical experience working with patients with multiple complex health issues.
Care management experience.

Responsibilities

Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leaders.
Execute core care management duties including comprehensive bio-psycho-social-spiritual assessments.
Collaborate with patients and care teams to develop patient-centered care plans, focusing on chronic disease management, social determinants, transitions of care, and advanced care planning (HCP, MOLST).
Implement care plans and collaborate with community partners such as VNA agencies, caregiver programs, DME providers, and social service agencies.
Assess goal completion and transition patients to inactive or graduated status as appropriate.
Utilize motivational interviewing techniques with reflective, empathetic language and open-ended questions to understand patient aspirations.
Meet patients at their current state, observing without intervention or judgment.
Educate patients on chronic medical 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 emergency services if not intervened upon.
Collaborate with Community Health Workers, Pharmacy team, and Social Workers, and follow up on completion.
Meet regularly with local clinical site leaders (Primary Care, ED, inpatient) and care management supervisor to triage program issues.
Participate in local site operations, including team meetings and curbsides with care team members.
Actively participate in planning and growth of the program with relevant stakeholders to respond to evolving needs of MassHealth ACO.
Facilitate interdisciplinary consultation on patients' behalf through participation in rounds, team meetings, and clinical reviews.
Comply with established performance metrics and adhere to documentation and work flow standards.
Maintain HIPAA standards and confidentiality of protected health information.
Adhere to departmental/organizational policies and procedures.
Work full-time at the clinical site of care.