Complex Care Manager RN

BMC Software • Arlington, MA

65d

About The Position

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. This position is Monday - Friday, 40 hours FTE, no weekends or holidays observed by BMC. Business hours, typically between 8:30 am - 5 pm. This position is a blended hybrid role, offering opportunities for both in person and remote work from home. Candidates must have a working vehicle and be able to travel independently. This role serves patients in the Brockton, Randolph, Raynham, Bridgewater, Easton and Quincy Communities. This position allows ~ 2 days per week working from home, ~ 3 days working in the community, practice site, patient home settings. The dress code is business casual.

Requirements

• Nursing degree: Diploma, ASN or BSN/Masters (preferred), Ability to obtain BSN within 4 years.
• Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts.
• A minimum of two years of clinical experience is preferred, with care management experience preferred.

Nice To Haves

• Experience working with vulnerable patient populations.
• Home care or clinic experience.
• Motivational interviewing experience.
• Clinical experience working with patients with multiple complex health issues.

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: Comprehensive assessment: bio-psycho-social-spiritual.
• Collaborate 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).
• Implement care plan; Collaborate with community partners, such as VNA agencies, caregiver programs (PCA, ADH, AFC), DME providers and social service agencies.
• Assess goal completion, with transition of patient to inactive or graduated status as appropriate.
• Use 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.
• 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.
• Collaborate with Community Health Workers and/or Social Workers.
• Meet regularly with leaders at the local clinical site (Primary Care, ED, inpatient), and care management supervisor, to triage program issues appropriately.
• Participate in local site operations, including team meetings, curbsides with care team members, etc.
• Actively participate in planning and growth of program with relevant stakeholders as needed, to respond to evolving needs of MassHealth ACO.
• Facilitate interdisciplinary consultation on patient’s behalf through participation in rounds, team meetings and clinical reviews.
• Comply with established metrics for performance and adhere to documentation and workflow standards.
• Maintain HIPAA standards and confidentiality of protected health information.
• Adhere to departmental/organizational policies and procedures.

Benefits

• Equal Opportunity Employer/Disabled/Veterans.
• Working at Boston Medical Center is more than a job. It’s a chance to make a difference as part of our mission to provide exceptional and equitable care to all.
• BMC is dedicated to improving the health of our community in Boston and beyond.
• BMC’s mission to provide exceptional care without exception extends to our employees.
• Recognized as a top employer and best place to work.

What This Job Offers

• Job Type: Full-time
• Education Level: Bachelor's degree
• Number of Employees: 1,001-5,000 employees