ACO RN Care Manager

Baystate Health • Springfield, MA

3d • Hybrid

About The Position

The RN Care Manager, ACO Transitions of Care is responsible for managing the care of a defined patient group, focusing on complex care management, transitions of care, and care coordination. Key duties include identifying patients for care management, creating individualized care plans, addressing barriers to care, performing medication reconciliation and titration, and ensuring adherence to quality measures. The primary goal is to help patients optimize chronic condition management, improve functional status, reinforce self-management, prevent complications, and reduce unnecessary emergency room visits and hospital admissions. This role involves collaboration with physicians and healthcare team members across the patient's care continuum, offering support through face-to-face interactions, home visits, and telephonic communication. Additionally, the RN Care Manager will assist with advance directives, palliative care, hospice, and end-of-life care coordination. Accurate documentation in patient medical records and care management applications is essential. The role requires accountability for professional practice and delegated patient care, operating within ethical and legal nursing standards. This description outlines essential functions, with the expectation of performing related duties as assigned.

Requirements

• Massachusetts RN License
• Driver’s License
• BLS CPR
• Minimum of 4 years of nursing experience
• 2 Years Care Management exp. experience preferred.
• Strong communication, interpersonal and problem-solving skills to advocate for optimal patient outcomes.
• Capacity to work closely with patients, physicians and their office staffs and managed care plans.
• Strong organizational and prioritization skills.
• Attention to detail and able to perform work independently.
• Excellent verbal and written communication and interpersonal skills.
• Associates Degree in Nursing (Required)
• Basic Life Support - American Heart Association
• Driver License - Other
• Registered Nurse - State of Massachusetts

Nice To Haves

• Bilingual skills preferred

Responsibilities

• Coordinates, oversees, and directs the interdisciplinary team members to provide care that is safe, timely, effective, efficient, equitable, and client-centered to the assigned patient population.
• Responsible for appropriately identifying patients for care management utilizing multiple sources including physician referrals, referrals from transitions of care, health plans as well as complex lists of patients from the ACO.
• Conducts whole person assessments to determine individual patient needs and create individualized self-management plans of care in conjunction with the patient/family.
• Evaluate the effectiveness of the plan of care and revise as necessary to meet goals.
• Assists patients to make informed decisions about their care by acting as their advocate regarding their clinical status and treatment options.
• Promotes quality and cost-effective interventions and outcomes to patients in collaboration with the primary care providers and/or specialists.
• Manages transitions of care for patients discharged from the hospital, behavioral health facility/program, emergency room, or from a skilled nursing facility.
• Responsible to review the discharge summaries, follow up on testing that is pending, ensure ordered services are in place.
• Outreaching to the patients to perform a medication reconciliation, ensure patients understanding of discharge instructions and assess for further care management needs.
• Providing disease management/complex care management to patients face to face or telephonically as well as utilizing technology that becomes available.
• Providing home visits to patients when appropriate.
• Titrating medications via protocols when necessary.
• Overseeing Care Coordinators and Community Health Workers which includes addressing quality indicators that are out of range and assisting patients to reach targets.
• Accountable for remaining current with knowledge of care management, availability of community resources and quality improvement methodologies
• Appropriate documentation in patient medical records and/or care management application is required and is vital.
• Care management program metrics including, emergency room utilization, and hospital admission/readmission data will be reviewed on a regular basis.
• Develops and collects data to identify trends in utilization of health care resources.
• Assumes accountability for own professional practice and for aspects of patient care delegated to others.
• Practices within the ethical and legal parameters of nursing practice.

Benefits

• High-quality, low-cost medical, dental and vision insurance
• Pet, home, auto and personal insurance
• 403b retirement company match & annual company contribution increase based on years of service
• Life insurance
• Reimbursement for a variety of wellbeing activities, included but limited to: gym membership and equipment, personal trainer, massage and so much more!

What This Job Offers

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