Nurse Care Manager - South Shore

On Belay Health Solutions•Boston, MA

3d•$115,000 - $125,000•Hybrid

About The Position

On Belay is seeking a motivated, passionate Care Manager to assist our provider partners’ Medicare patients. The goal of the care manager is to assist identified patients with developing their health goals and creating a plan to manage real life issues that keep them from achieving those goals. The Care Manager will collaborate with other team members to conduct needs assessments and identify and respond to barriers to their health and wellness. Benefits include a generous holiday and paid time off policy. Health and dental reimbursement plans. Applicants must be based in the Boston Metro (South Shore), Massachusetts area and be willing to perform duties onsite with our physician practice partners twice a week within one hour driving distance. On Belay is open to flexible work arrangements, including remote work on offsite days. We look forward to meeting interested applicants and mutually assessing fit in joining On Belay on our important mission to transform healthcare!

Requirements

Current unrestricted Massachusetts RN license required
Previous work experience in a primary care setting, emergency medicine setting, care management role, and/or a home care manager
Must be a self-directed individual able to work diligently without direction, think critically and prioritize.
Basic computer skills including working knowledge of Microsoft Office products
Demonstrated experience with Electronic Medical Records (EMR) systems, with a strong preference for proficiency in EPIC
English fluency is required.

Nice To Haves

CCM (Certified Case Manager) or ACM (Accredited Case Manager), preferred
Bachelor's degree or higher , preferred
Experience working with aging population and/or community health, preferred
Knowledge of health plans, Medicare, Medicaid, preferred
Current unrestricted Compact Nurse Licensure in addition to MA RN license
CCM (Certified Case Manager) or ACM (Accredited Case Manager)
Bachelor's degree or higher
Experience working with aging population and/or community health
Knowledge of health plans, Medicare, Medicaid
Verifiable good driving record and reliable transportation
Spanish, Haitian Creole, or Vietnamese helpful.

Responsibilities

Develop trusting relationship with patients by providing support and advocacy to help achieve health goals
Coordinate transitions of patients to/from acute inpatient, skilled nursing and other settings.
Assist patients in accessing community resources (e.g., food stamps, meals on wheels, subsidized housing, free legal services, Medicaid/Medicare applications, support groups etc.)
Meet with patients in patient-centered and patient-preferred locations (e.g., center, facility, home, community setting).
Manage low-risk referrals defined by care management program (Medical Social Work) & collaborate with social worker on action plan
Engage with high-risk individuals (e.g., completed specialty appointments, adherence to post-discharge visits); may include accompanying patients to appointments
Assist completion of applications to access eligible benefits
Perform wellness checks in homes, participate in remote monitoring program education on individuals with specific health conditions
Provide health screenings, referrals and information
Deliver health education presentations
Facilitate communication between all identified parties by the patient involved in care (e.g., family members, care givers, medical providers, community-based organizations).
Document interactions with patients in medical record
Coach / train early career Care Managers, potentially in a management role
Any other related duties assigned at manager’s discretion