Emerging Risk Care Manager, RN

Mass General Brigham • Somerville, MA

1d • $58,656 - $142,449 • Hybrid

About The Position

The Emerging Risk RN Care Manager is a key clinical member of the Emerging Risk Program, a component of the CARE Compass Program. This role is responsible for providing high-quality, patient-centered care management for individuals identified as “rising risk” based on medical conditions, SDOH needs, and an inflection in utilization patterns. Operating at the top of license, the RN Care Manager focuses on clinical assessment and design of time-limited goals promoting positive patient outcomes. She/he engages with the patient/family in proactive care planning, symptom identification, and reinforcement of treatment plans, with patient education to support engagement with primary care and successful linkage to community resources. These efforts align with the Care Compass mission of enhancing stability at home, improved outcomes, and reduction in ED and hospital utilization. Working within a defined interdisciplinary team including Community Health Workers and Patient Navigators, the RN CM will support the identification of patients with medical conditions and gaps in care which may contribute to either an uptick or anticipated uptick in utilization. Understanding that SDOH strongly influences disease management, the RN Care Manager will need to work closely with a non-clinical bachelor’s-level Community Health Workers and Patient Navigator (CCC) Care Coordinator to provide administrative and logistical support. Together, this multidisciplinary team will offer time-limited, goal-directed, patient-centered care coordination. The team will have access to behavioral health expertise and may refer to a pharmacist who specializes in medication management, MTM, and can provide medication reconciliation. This team-based model allows the RN to focus on patients with new or chronic medical conditions, ensuring the highest level of efficiency and effectiveness. The RN Care Manager is also responsible for ensuring compliance with complex care documentation requirements, payor contract care management requirements, and may support quality measures to improve patient outcomes. The RN Care Manager is flexible and can adapt to an ever-changing healthcare environment. This role requires a willingness to assess, participate in ongoing process improvement activities, and innovate processes and workflows to support time-limited, targeted care coordination. This role will utilize a variety of intervention modes including but not limited to video, telephone, and patient gateway (MGB Patient Portal).

Requirements

• Associate’s Degree Nursing required.
• RN license required.
• Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
• Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
• Ability to establish strong rapport and relationships with patients and staff.
• Proficient in Microsoft Office and industry related software programs.
• Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
• Ability to maintain client and staff confidentiality.
• Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.

Nice To Haves

• Bachelor’s Science Nursing preferred.
• 2+ years case management, utilization review and/or discharge planning experience preferred.
• Experience with health coaching preferred.
• Experience with SDOH and/or BH preferred.
• Knowledge of Healthcare and Managed Care preferred.

Responsibilities

• Providing high-quality, patient-centered care management for individuals identified as “rising risk” based on medical conditions, SDOH needs and an inflection in utilization patterns.
• Operating at the top of license, focusing on clinical assessment and design of time-limited goals promoting positive patient outcomes.
• Engaging with the patient/family in proactive care planning, symptom identification and reinforcement of treatment plans.
• Providing patient education to support engagement with primary care and successful linkage to community resources.
• Supporting identification of patients with medical conditions and gaps in care which may contribute to either an uptick or anticipated uptick in utilization.
• Working closely with a non-clinical bachelor’s-level Community Health Workers and Patient Navigator (CCC) Care Coordinator to provide administrative and logistical support.
• Ensuring compliance with complex care documentation requirements and payor contract care management requirements.
• Supporting quality measures to improve patient outcomes.
• Assessing, participating in ongoing process improvement activities, and innovating processes and workflows to support time-limited targeted care coordination.
• Utilizing a variety of intervention modes including but not limited to video, telephone and patient gateway (MGB Patient Portal).

Benefits

• Comprehensive benefits
• Career advancement opportunities
• Differentials, premiums and bonuses as applicable
• Recognition programs designed to celebrate your contributions and support your professional growth.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree