(RN) Complex Discharge Planner, Nursing

Community Care Cooperative•Boston, MA

63d•Hybrid

About The Position

As an integral member of the care management team, the Complex Discharge Planner will have the opportunity to have a profound impact on the lives of people living with complex and/or chronic conditions, many of whom also face multiple barriers in their lives, which make it difficult for them to achieve the self-care required to improve their health and well-being. This role plays a key part in advancing value-based care by improving care transitions, reducing avoidable ED utilization and readmissions, and promoting equitable, person-centered care. This position is currently hybrid, but requires flexibility, and may vary from day-to-day to meet members where they are. Outreach methods are based on the needs of the organization and the member, and may include telephonic, or in-person engagements in a variety of potential settings, such as the health center/practice, community, home, or an inpatient facility.

Requirements

Demonstrated success in identifying and supporting members with high utilizer patterns, complex needs, and social risk factors to reduce avoidable readmissions and improve continuity of care
Vital part of a multi-disciplinary team including communicating and working with Providers, Pharmacists, Social Workers, Community Health Workers, and other health care teams
Must be flexible and adaptable to change
Experience using appropriate technology, such as computers, for work-based communication
Experience and proficiency with Microsoft Office and online record keeping
Demonstrate the ability to work independently
Experience within the ACO's member population preferred, including Medicare/Medicaid member populations
Acute hospital (Medical or BH) discharge planning experience strongly recommended
Familiarity with DCP Levels of Care (Acute, Subacute, Outpatient, Respite, Home Health) and Ancillary Services (DME)
Experience working with Federally Qualified Health Centers/ Primary Care Provider practices is strongly preferred
RN/LPN with current, active MA nursing license
3-5 years of nursing experience; acute hospital/ED, home health care, ambulatory care, community public health or Case/Care Management
A valid driver's license and provision of a working vehicle
Experience with anti-racism activities, and/or lived experience with racism is highly preferred

Nice To Haves

Must demonstrate excellent interpersonal communication skills; strong negotiator
Ability to flexibly utilize clinical expertise to solve complex problems
Experience working with patients with chronic medical and behavioral health needs
Bi/multi-lingual preferred

Responsibilities

Manages complex discharge planning needs for members (adult and pediatric) experiencing extended inpatient stays or frequent ED visits, and actively participates in regular meetings with hospital staff, providers, care team, and community services
May be required to meet members while they are inpatient or in the ED to provide education and support about the discharge process, and to transition members into care management
Manages complex care coordination needs, inclusive of medical, behavioral health, and SDOH needs, in partnership with Community Health Workers/Care Coordinators and Community Partner Agencies
Partners with MassHealth and other state agency contacts to facilitate care transitions to the safest level of care
Active participation in a member's discharge planning needs
Supports the completion of referrals, and/or providing or confirming appropriate follow-up
Conducts Comprehensive Clinical Assessments for adult and pediatric members
Ensure that medication reconciliation is completed, as indicated. Nurse CMs will complete a medication reconciliation, which may include support from a pharmacist and/or primary care team
Actively engages members and caregivers in collaborative care planning, focusing on medical, behavioral, social, and member-centered needs. Coaches and guides member/representative to meet bio/psycho/social goals
Assesses the member's knowledge of their medical, behavioral health, and/or social conditions, and provides education and self-management support plans based on the member's needs and preferences
Connects members with primary care, behavioral health, social services, Community Partner, respite, and other community-based services, as indicated and appropriate
In collaboration with Community Health Workers, creates and maintains a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services
Participates in the integrated care team meetings and clinical rounds, as required
Maintain accurate, timely documentation in electronic systems, including health center/practice EHRs
Provides coverage for other Discharge Planning team members who are out of office
Other duties as assigned