Nurse Care Manager, Primary Care

Mass General Brigham • Oak Bluffs, MA

3d • Remote

About The Position

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. The Mass General Brigham Medical Group is a system-led operating entity formed by Mass General Brigham to deliver high quality, low cost, innovative community-based ambulatory care. This work stems from Mass General Brigham’s unified system strategy to bring health care closer to patients while lowering total health care costs. The Medical Group provides a wide range of offerings, including primary care, specialty care, behavioral and mental health, and urgent care, both digitally as well as at physical locations in Massachusetts, New Hampshire, and Maine. The group also offers outpatient surgery and endoscopy, imaging, cardiac testing, and infusion. We share the commitment to delivering a coordinated and comprehensive experience across all locations, ensuring the appropriate level of care is available to every patient across our care delivery sites. We are constantly aiming to improve access for patients and to meet the evolving health care needs of the communities we serve. Primary care is all about relationship-building! We pride ourselves on our true patient-centered medical home model for our patient’s care. The whole team really gets to know our patients to ensure that they are receiving exceptional, personalized care in a comfortable, friendly atmosphere.
We are seeking a 36-hour Transitional Care Nurse Case Manager to join our fully remote team, working Monday through Friday, 8:00 AM – 4:30 PM. In this role, you will spend your day on the phone, reaching out to patients discharged from hospitals, rehabs, and emergency rooms, collecting medical history, performing clinical screenings, and ensuring they are connected with their primary care providers. Calls are often 45 minutes or longer and require detailed documentation in Epic. The ideal candidate will have at least an Associate’s degree in Nursing, with a primary care or hospital nursing background, be comfortable working autonomously, and be highly organized and skilled at phone-based clinical care. Epic experience is a plus. Serves as a core member of the care team coordinates and supports healthcare within the facility, and coordinates referrals for services outside the clinic. Provides outreach and enrollment services to meet eligibility requirements of the program and surrounding counties. Ensures coordination and planning, including community and family support. Focuses on the development and coordination of community service plans. Partners with service providers, families, and patients to create a plan of healthcare and identify additional service providers.

Requirements

• Associate's Degree Nursing required or Bachelor's Degree Nursing preferred
• Registered Nurse [RN - State License] required
• Case management, utilization review, or discharge planning experience 2-3 years preferred
• 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.
• Knowledge of Healthcare and Managed Care preferred

Nice To Haves

• Basic Life Support [BLS Certification] preferred
• Epic experience is a plus

Responsibilities

• Client Assessments and Planning
• Modify patient treatment plans as indicated by patients' responses and conditions.
• Prepare patient/family for discharge
• Communicates with third party payers to obtain necessary authorization for reimbursement of services.
• Review cases with medical directors on challenging cases as needed
• Defines care goals of patients by providing education, information, and direction to each individual and family.
• Maintain accurate, detailed reports and records.
• Communicates with third party payers to obtain necessary authorization for reimbursement of services.

What This Job Offers

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