Registered Nurse (RN), Care Manager

About the position

BILHPN has oversight of population health and is responsible to ensure that quality, efficient care management services are provided to the BILHPN provider's risk populations. The Care Manager, RN 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 care plans on 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 all settings to optimize quality and efficient outcomes; and decrease total medical expenses. The Care Manager, RN assesses, plans, implements, coordinates, monitors and evaluates options and services to meet the individual patient needs. This role is a hybrid position. The Care Manager works closely with 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, RN builds relationships with the patient through use of motivational interviewing techniques to promote engagement in healthy behavior. Working with the healthcare team, the Care Manager, RN monitors appropriate utilization of healthcare resources, promotes quality and efficiency by developing and implementing a patient centered care plan. The RN 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, RN upholds the current standards of professional case management practice, and reports to the Manager of Care Management.

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.
• Offers and coordinates free care consultation to patient/caregiver telephonically, to reinforce condition management, provide education and community resource navigation.
• Develops comprehensive care plans in collaboration with patient, physician and health care team based on evidence-based best practice for chronic condition management.
• Creates a patient-centered care plan that addresses problems/barriers and develops action plan relevant to obstacles in chronic condition management.
• Refers patients to appropriate community resources and support programs.
• Serves as the central resource for the physicians and practice team for the Medicare ACO population functioning as navigator, coach, and condition manager for the targeted patient population.
• Collaborates with patients to facilitate healthy behaviors.
• Utilizes coaching to foster healthy lifestyle management.
• Helps patients to learn strategies and skills designed to stabilize symptoms and prevent condition progression.
• 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.
• Reviews at risk patients with providers to understand drivers of cost, current treatment plan, future course and prognosis.
• Ensures advance directives and appropriate referrals are addressed, such as palliative/hospice, and makes recommendations for cost reduction alternatives whenever appropriate.
• Seizes opportunities to reduce gaps in care by making recommendations for efficiency, quality and cost improvement.
• Conducts formal reassessments at prescribed intervals and whenever there is a significant change in the patient's health, abilities, living situation, and family involvement.
• Works collaboratively with other professionals to maintain a team oriented approach to care management and incorporates shared decision making in all patient interactions.

Requirements

• BSN preferred, experience in care management and health care system considered in lieu of degree.
• Active, unrestricted Massachusetts Registered Nurse License required.
• Certification in Case Management (CCM) preferred.
• NH Licensure or reciprocity desirable.
• Case management and nursing experience preferred.
• Experience with coaching while working with the chronic, complex population in a physician management service organization is desirable.
• Experience with Commercial Insurance quality gap closure and Medicare population in managed care, medical home or integrated case management environment is preferred.
• Must be proficient in computer skills, internet, information technology and electronic medical record use.

Benefits

• Hybrid/remote work option.
• Full-time employment.