Care Manager, Transitions of Care, RN-Hybrid

Job Summary

The Clinical Care Manager provides holistic care management services for members throughout the continuum of care by assessing the member clinically as well as member’s readiness to make behavioral changes and actively participate in a care plan, establish goals and meet those goals. Wellsense Health Plan members may include those who have chronic conditions and complex care needs, including those considered to be the highest risk members those who are homeless, undergoing organ transplantation, have multiple clinical and behavioral co-morbid conditions, and with special health care needs. The clinician works collaboratively with a multidisciplinary team (both internal and external) including providers, our clinical vendor partners (pharmacy, etc.) and community/State agencies to increase patient knowledge, motivation, and compliance with treatment through targeted interventions that address the member’s holistic needs from a medical and psychosocial/socioeconomic standpoint. Following this approach, the goal is to improve member health outcomes and decrease overall cost while improving the member’s overall experience with the health care delivery system.

Key Functions/Responsibilities

• Supports programs and clinical best practices with the objective of improving health outcomes, preventing hospital readmissions, improving member safety and reducing medical errors, and promoting health and wellness activities, where appropriate.
• Completes a transitional care management assessment and applicable condition specific assessments.
• Collaborate with hospitals to ensure a seamless transition of care upon admission and discharge to the community, and detail information sharing and collaboration between the Health Plan and the participating hospital
• Coordinates member care transitions through pre-admission assessments, post-discharge assessment and follow-up to ensure appointment is made with the PCP or Specialist; assessing for home health services, DME needs, and transportation issues; performing medication reconciliation; ensuring compliance with discharge plan, appointments and medication regimen.
• Uses available standardized educational materials in an appropriate reading level to educate members about their conditions.
• Maintain members’ labs, tests results, appointments and other data in order to best coordinate care utilizing EMR (where available and appropriate) and the Plan’s care management software.
• Evaluates members’ need for complex care management, disease management or care management services.
• Collaboratively develops an individualized care plan with the member focusing on the member’s goals and objectives, identifying strategies, supports and/or services needed to achieve short and long term goals.
• Identifies and addresses barriers to optimal self-management and works with the member and team to coordinate care throughout the health care continuum.
• Affords the member to access all available benefits and resources including family support and community resources.
• Utilizes motivational interviewing techniques to engage members in care management and to coach members regarding health promotion, disease management and preventive health strategies.
• Uses real-time data from electronic medical records, where available.
• Uses Wellsense Health Plan reporting to access member medical and pharmacy utilization reports, sharing with PCP, to promote medication compliance and action plans.
• Supports and enhances the member’s capacity to self-manage.
• Evaluates the effectiveness of the care management provided to the member on an on-going basis and updates the ICP accordingly.
• Utilizes evidence-based practices and guidelines to educate members on specific disease processes.
• Provides or arranges for resources necessary to meet members’ psychosocial and socioeconomic needs.
• Promotes and encourages member collaboration with the primary care provider and other health care providers.
• Completes documentation in the medical management information system real-time during face-to-face meetings, by phone, and in a timely manner and in keeping with contractual requirements, internal policy and NCQA accreditation standards. Facilitates multidisciplinary consultation on members’ behalf through participation in rounds, team meetings and clinical reviews.
• Conducts face-to-face visits with members and providers, community and state agencies, as appropriate.
• Affords assistance with staff training and mentoring.
• Maintains HIPPA standards and confidentiality of protected health information.
• Demonstrates strong knowledge of contractual requirements of all Wellsense products and provides cross coverage across product lines when needed.
• Adheres to departmental/organizational policies and procedures.
• Other duties as assigned.

Qualifications

• Education Required: Bachelor’s degree in nursing or Associate’s degree in Nursing and relevant work experience.
• Experience Required: 3 years related experience in home health care or managed care organization, 3 years clinical experience working with members who have multiple, chronic or complex health conditions, 2 years’ experience in care management, care coordination and/or discharge planning.
• Experience Preferred/Desirable: Experience working with Medicaid recipients and community services, Experience with FACETS, Jiva, Interqual or other healthcare database.
• Required Licensure, Certification or Conditions of Employment: Pre-employment background check, Current unrestricted, applicable, state license to practice as a Registered Nurse in Massachusetts. CCM certification preferred, Regular and reliable transportation and the ability to conduct face-to-face appointments with members, providers, community and state agencies.
• Competencies, Skills, and Attributes: Strong Motivational Interviewing skills, Strong oral and written communication skills, Ability to effectively collaborate with health care providers and all members of the multidisciplinary team, Strong technical skills and ability to document in the Plan’s care management documentation system in real-time when meeting with members and providers in-person or by phone, Demonstrated organizational and time management skills, Able to work in a fast paced environment, Experience with Microsoft Office application, particularly MS Outlook and MS Word and other data entry processing applications, Strong analytical and clinical problem solving skills.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.