Complex Care Manager RN, Full Time

We need to output HTML fragment with headings

for sections: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections that have real specific content. Must not repeat job title as heading. Must not include Job ID etc. Must preserve all substantive info, no invented or summarizing away detail. Remove boilerplate (cookie/navigation/legal/EEO/equal-opportunity/scam-warning). Also remove duplicated lines, application instructions. We need to parse the posting. Let's extract sections: - Position Summary: description about role. Could be "About the role". We'll put that under

About the role

with paragraphs. - Key Functions/Responsibilities: list of duties. Use

• . - Education: JOB REQUIREMENTS: Nursing degree etc. Could be under Requirements or Qualifications. The instruction: Use headings for sections like Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We need to decide mapping. We have content: Education, Experience, Certification Or Conditions Of Employment, Knowledge And Skills, etc. We can combine into sections: Requirements (education, experience, certification), Skills (knowledge and skills), Benefits (compensation range and benefits description), Pay (maybe separate but we have compensation range; we could put under Pay). Schedule: they gave "Schedule: Full Time". Also hybrid role mention. So we can have Schedule section. We must not create sections with filler like "commensurate with experience". We have actual content. We must not include EEO etc. Remove scam warning. We must not include duplicated lines. Let's extract substantive content: Position Summary paragraph: "The Complex Care Manager works with relevant stakeholders to identify and engage patients in care management with a focus on patient experience, improving health and reducing cost. The individual is responsible for working with patients to identify strengths and barriers and to develop an individualized, patient-centered care plan. Excellent interpersonal skills, clinical expertise in conditions prevalent in the Medicaid population (Substance Use Disorder, Serious Mental Illness, Congestive Heart Failure [CHF], etc.), patient engagement skills and the ability to work independently and collaboratively are key requirements of the job. This position is a hybrid role requiring community and clinic presence as assigned, as well as an opportunity to work from home. Nurses in the position will work in 2 programs: Primary Care-based Complex Care Management and Transitions of Care. Nurses will collaborate closely with one another in the care of shared patients. Nurses will be designated to one of three clinical sites depending on the specific program he/she is a part of: Primary Care Practice, Emergency Department (ED), or Inpatient. Details on the 3 Care Management Programs are described below: Primary Care-based Complex Care Management: The CCM team will be embedded in local primary care practices. The team will partner closely with PCPs, Integrated Behavioral Health Professionals, Pharmacists, and other local resources in the Primary Care Practice to develop multi-disciplinary care plans. Nurses will proactively seek out opportunities to care for patients, including during PC visits, during ED or IP visits, out in the community, or on the phone. Nurses will be paired with Community Wellness Advocates who will partner with nurses on a shared patient panel, and will focus on social determinants of health. Transitions of Care (TOC): The Transitions of Care RN or SW provides comprehensive, wrap-around care for patients during their inpatient stay and immediately after their discharge. The RN/SW specifically works with patients who have the greatest risk of readmissions. By complementing existing care teams on the inpatient and outpatient side, the TOC RN/SW serves a critical role in connecting the dots across care providers and community agencies. The TOC RN/SW works at inpatient facilities, and aims to fully integrate with inpatient care operations – documenting in local medical records, participating in care planning efforts, etc. to ensure seamless care planning for patients while also serving as the link to continuing outpatient care. Clinical expertise in common high-risk medical conditions (e.g. CHF, diabetes, COPD, etc.), familiarity with home health and community-based resources, experience working at a safety-net facility or with the Medicaid population as well as excellent interpersonal skills, patient engagement skills and the ability to work independently and collaboratively are key requirements of the job." That's a lot; we can keep as prose. Key Functions/Responsibilities list: "ESSENTIAL RESPONSIBILITIES / DUTIES: Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leadersAbility to execute core care management duties:Comprehensive assessment: bio-psycho-social-spiritualCollaboration with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning (HCP, MOLST)Implementation of care plan;Collaboration with community partners, such as VNA agencies, caregiver programs (PCA, ADH, AFC), DME providers and social service agencies; 5) assessment of goal completion, with transition of patient to inactive or graduated status as appropriate.Uses reflective, empathetic language and open-ended questions to understand what the patient truly wants for him/herself beyond being healthy and staying out of the hospitalMeet the patient where he/she is; observe the patient without intervention or judgmentHas knowledge of common chronic medical conditions presented in the population served and is able to:Educate the patient on their medication conditions and medications, and build their self-management skills;Use motivational interviewing to promote behavioral change;Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.Meets regularly with leaders at the local clinical site (Primary Care, ED, inpatient), and care management supervisor, to triage program issues appropriately.Participates in local site operations, including team meetings, curbsides with care team members, etc.Actively participates in planning and growth of program with relevant stakeholders as needed, to respond to evolving needs of MassHealth ACO.Facilitates interdisciplinary consultation on patient’s behalf through participation in rounds, team meetings and clinical reviewsComplies with established metrics for performance and adheres to documentation and work flow standardsMaintains HIPAA standards and confidentiality of protected health information.Adheres to departmental/organizational policies and procedures.Care Manager will work full-time at the clinical site of care Metrics ED and inpatient visitsTotal medical expensePatient satisfactionClinical outcomesProvider satisfactionAvoidable admissions Other duties as assigned" We need to split into list items. The text is messy; we can parse each duty separated by numbers or colons. Let's extract bullet points: - Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leaders - Ability to execute core care management duties: - Comprehensive assessment: bio-psycho-social-spiritual - Collaboration with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning (HCP, MOLST) - Implementation of care plan; - Collaboration with community partners, such as VNA agencies, caregiver programs (PCA, ADH, AFC), DME providers and social service agencies; - Assessment of goal completion, with transition of patient to inactive or graduated status as appropriate. - Uses reflective, empathetic language and open-ended questions to understand what the patient truly wants for him/herself beyond being healthy and staying out of the hospital - Meet the patient where he/she is; observe the patient without intervention or judgment - Has knowledge of common chronic medical conditions presented in the population served and is able to: - Educate the patient on their medication conditions and medications, and build their self-management skills; - Use motivational interviewing to promote behavioral change; - Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon. - Meets regularly with leaders at the local clinical site (Primary Care, ED, inpatient), and care management supervisor, to triage program issues appropriately. - Participates in local site operations, including team meetings, curbsides with care team members, etc. - Actively participates in planning and growth of program with relevant stakeholders as needed, to respond to evolving needs of MassHealth ACO. - Facilitates interdisciplinary consultation on patient’s behalf through participation in rounds, team meetings and clinical reviews - Complies with established metrics for performance and adheres to documentation and work flow standards - Maintains HIPAA standards and confidentiality of protected health information. - Adheres to departmental/organizational policies and procedures. - Care Manager will work full-time at the clinical site of care - Metrics: ED and inpatient visits, Total medical expense, Patient satisfaction, Clinical outcomes, Provider satisfaction, Avoidable admissions - Other duties as assigned We'll produce
  • for each. Education section: "Education JOB REQUIREMENTS Nursing degree: Diploma, ASN or BSN (preferred), Ability to obtain BSN within 4 yearsBS or Master's in Nursing preferred" We need to parse: "Nursing degree: Diploma, ASN or BSN (preferred), Ability to obtain BSN within 4 yearsBS or Master's in Nursing preferred". Probably missing space. We'll produce list. Experience: "Experience A minimum of two years of clinical experience is preferred, with care management experience preferredExperience working with vulnerable patient populations preferredHome care or clinic preferredMotivational interviewing preferredClinical experience working with patients with multiple complex health issues preferredCare management preferred" We'll list. Certification Or Conditions Of Employment: "Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts requiredDriver’s license and reliable access to a vehicle required" Knowledge And Skills: "Excellent interpersonal skills and ability to work collaborativelySelf-management skills, including ability to prioritize and set patient-centered goalsExcellent written and verbal communicationAble to maintain professional boundariesAbility to work with diverse, safety-net populationSkilled at engaging difficult to engage patients—build rapport, trustCreative problem solverAbility to adapt to changes in healthcare delivery at local and systems levelExtensive knowledge of healthcare systems and community resourcesAbility to leverage systems and resources for improved patient outcomesStrong organizational and time management skills" We'll list. Compensation Range: "NursingCM Compensation Range $89,500.00- $130,000.00 This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensures as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), discretionary annual bonuses and merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family well-being. NOTE: This range is based on Boston-area data, and is subject to modification based on geographic location." We need Pay section maybe with salary range and benefits. Benefits section maybe separate. But we can combine Pay and Benefits? The instruction: Use headings for Benefits, Pay, Schedule. We should separate if we have content. We have compensation range (Pay) and benefits description (benefits). So we can have

    Pay

    with paragraph about salary range and note. And

    Benefits

    with list of benefits. Schedule: "Position: Complex Care Manager RN Department: Pop Health Care Management Schedule: Full Time Location: North Shore Region". Also hybrid role mention earlier. So schedule: Full Time, hybrid (community/clinic presence and work from home). We'll put schedule section. We must not repeat job title as heading. Already not. We must not include Job ID etc. Not present. We must not include EEO etc. Remove. We must not include scam warning. Remove. Now produce HTML fragment. Structure:

    About the role

    ... (position summary paragraphs)