Complex Care Manager RN, Pop Health, 40 Hours (Days)

Position Summary 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. Position: Complex Care Manager RN Department: Pop Health Schedule: Full Time, 40 hours a week Monday through Friday business hours. No weekends, no major holidays observed by BMC Essential Responsibilities / Duties Compensation will be based on a salary/incentive plan. Key Functions/Responsibilities 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 motivational interviewing: 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.Collaborates with Community Health Workers, Pharmacy team, and Social Workers and follows up on completion. 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 Job Requirements Other duties as assigned Education Nursing degree: Diploma, ASN or BSN (preferred), Ability to obtain BSN within 4 years requiredBS or Masters in Nursing preferred Certificates, Licenses, Registrations Required CCM Certification preferredLicensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts AND/OR Completed an accredited educational program for Nurse Practitioners Experience A minimum of two years of clinical experience is preferred, with care management experience preferred Preferred Experience Experience working with vulnerable patient populationsHome care or clinicMotivational interviewingClinical experience working with patients with multiple complex health issuesCare management 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 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. Equal Opportunity Employer/Disabled/Veterans According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or “apps” job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment.