Nurse Care Manager

Beth Israel Lahey Health•Wakefield, MA

8d•$95,000 - $130,000•Onsite

About The Position

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives. BILHPN has oversight of population health and is responsible to ensure that quality and efficient care management services are provided to the BILHPN provider’s risk populations. The Care Manager provides care management services to the BILHPN primary care physicians focusing on at risk, high cost, and chronic/complex condition patient populations. Collaborates with the primary care team to develop strategies for their at-risk patient population through care coordination, condition management education and community resource support. Responsibilities include working with physicians, patients, families, and the multidisciplinary team in all settings to optimize quality, reduce readmissions and decrease total medical expenses. The Care Manager assesses, plans, implements, coordinates, monitors and evaluates options and services to meet the individual patient needs. This role works closely with the skilled nursing facility team, the primary care provider and patient to develop collaborative care plans to improve self-management of chronic conditions utilizing evidence-based best practice standards. The Care Manager is accountable for ensuring efficient and professional services for patients and families that are designed to promote and enhance their physical and psychological functioning with attention to the social and emotional impact of illness and disability. The Care Manager upholds the current standards of professional case management practice, and reports to the Post-Acute Program Director.

Requirements

Graduation from a practical nursing program or nursing program.
Active, unrestricted Massachusetts or New Hampshire LPN or RN license.
Case management and nursing experience preferred.
Experience working in Skilled Nursing Facilities with in depth knowledge of Medicare Guidelines preferred
Experience with Medicare population in managed care preferred
Must be proficient in computer skills, internet, information technology and electronic medical record use.
Strong development, analytic and systems building skills.
Must be facile with physician relations, developing systems and procedures, developing and operating a capitated managed care infrastructure, continuous quality improvement, human resources management and fiscal management.
Excellent written and verbal communication skills.
Must have a professional demeanor and the ability to deal with physicians, senior management, and local industry.
Capable of serving as a spokesperson and leader of the integration process and communicate the vision to others in the community.
A well-defined style that demonstrates confidence, maturity, self-motivation, high energy, collaboration, high intellect and leadership qualities.
Excellent interpersonal skills, be an appropriate risk taker, politically savvy, diplomatic, able to deal with ambiguity, flexible, organized, results oriented, a hard worker, a quick study, good with details and have integrity.
Ability to function as a facilitator who can further the organization to serve the evolving Network.

Nice To Haves

Certification in Case Management (CCM) preferred.

Responsibilities

Supports the primary/specialty care physicians in population health management by focusing care coordination attention on the at-risk population driving utilization and costs to improve efficiency, quality and patient satisfaction.
Engages physician and practice team in proactive patient management by addressing medical /psychosocial/functional health care needs, follow-up, and referrals.
Utilizes a designated patient roster report to review at risk population with providers and the Post-Acute Program Director to prioritize program enrollment, care planning, addressing prognosis and potential palliative/hospice care referrals.
Offers and coordinates free care consultation to patient/caregiver telephonically, to reinforce appropriate follow up care, condition management, provide education and community resource navigation.
Aims to improve the individual’s overall quality of life by supporting treatment goals, empowering them to be advocates for themselves and assisting them to obtain benefits, access to health care and connect to social and community services.
Advocates for patient and families, responds to and facilitates resolution of patient questions and concerns.
Seizes opportunities to reduce gaps in care by making recommendations for efficiency, quality and cost improvement.
Understands organizational goals and accountability towards maximizing organization performance.
Works collaboratively with other professionals to maintain a team-oriented approach to care management and incorporates shared decision making in all patient interactions.
Interfaces at prescribed intervals with patients, families, the health care team, community agencies, vendors, and health system staff to ensure efficient, quality care delivery.
Reviews at risk cases with the Post-Acute Program Director and Medical Director as needed, in a concise, effective, professional manner.
Addresses medical /psychosocial concerns and makes recommendations to improve efficiency and quality care.
Serves as an educational/informational resource to the provider care team, and patient/family regarding inpatient/outpatient resources.
Participates in care team huddles by communicating important information on at risk cases with interdisciplinary team.
Documents in the case management record clear, concise, timely notes that addresses patient problems, barriers, goals, support systems, advance directives, transition plan and case management interventions to improve efficiency, quality and reduce cost.
Strives to provide a quality patient and provider experience while working in collaboration with the patient/family and members of the healthcare team.
Coordinates care to maximize the value of services delivered to patients to improve health care outcomes.
Incorporates shared decision making in all aspects of patient care interactions.
Promotes patient autonomy and self-management at every encounter.
Creates a culturally sensitive care plan while utilizing health literacy and language appropriate patient education materials to promote engagement in plan.
Responsible for timely reporting of quality events in the inpatient/outpatient care setting to ensure continuous monitoring for quality improvement.
Refers quality/risk management cases to the Post-Acute Program Director or Medical Director and reports events per BILHPN policies, regulatory and /or health plan requirements.
Identifies opportunities to improve patient adherence with ACO quality measures.
Reports and follows up on patient complaints to ensure quality care and patient satisfaction.
Participates in quality improvement projects and other educational sessions offered by the employer to promote continuous learning.
Maintain strict adherence to the Lahey Health Confidentiality policy.
Incorporate Lahey Health Standards of Behavior and Guiding Principles into daily activities.
Comply with all Lahey Health Policies.
Comply with behavioral expectations of the department and BILHPN.
Maintain courteous and effective interactions with colleagues and patients.
Demonstrate an understanding of the job description, performance expectations, and competency assessment.
Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.
Participate in departmental and/or interdepartmental quality improvement activities.
Participate in and successfully completes Mandatory Education.
Perform all other duties as needed or directed to meet the needs of the department.