Overview The Complex Care Manager RN partners with stakeholders to identify and engage patients in care management with a focus on the patient experience, improving health, and reducing cost. This role directs and manages Community Health Workers and/or Patient Navigators in completion of patient care tasks. The individual works with patients to identify strengths and barriers and develops an individualized, patient-centered care plan. Clinical expertise in conditions prevalent in the Medicaid population (e.g., Substance Use Disorder, Serious Mental Illness, Congestive Heart Failure) and strong patient engagement skills are required, along with the ability to work independently and collaboratively.
This position is Monday – Friday, 40 hours per week, with no weekends or holidays observed by BMC. Business hours are typically 8:30 am – 5:00 pm. It is a blended hybrid role with in-person and remote work from home opportunities. Candidates must have a working vehicle and be able to travel independently. The role serves patients in the Brockton, Randolph, Raynham, Bridgewater, Easton and Quincy communities, with approximately 2 days per week working from home and ~3 days in the community, practice site, or patient home settings. The dress code is business casual. The Complex Care Manager will be embedded in local primary care practices and will partner with PCPs, Integrated Behavioral Health Professionals, Pharmacists, and other local resources to develop multi-disciplinary care plans. Nurses will collaborate with Community Wellness Advocates on a shared patient panel to address social determinants of health.
Compensation will be based on a salary/incentive plan.
Location details and job postings do not convey guarantees of employment and are subject to change. This description may include references to additional duties and responsibilities as needed.
Essential Responsibilities / Duties Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leaders
Execute core care management duties, including:
Comprehensive bio-psycho-social-spiritual assessment
Collaborate with patient and care team to develop a patient-centered care plan, focusing on chronic disease management, social determinants of health, transitions of care, and advanced care planning (HCP, MOLST)
Implement and monitor the care plan
Coordinate with community partners (e.g., VNA agencies, caregiver programs, DME providers, social service agencies) and assess goal attainment with appropriate transitions of care
Use reflective, empathetic language and open-ended questions to understand what the patient truly wants
Meet the patient where they are; observe the patient without judgment
Demonstrate knowledge of common chronic conditions in the served population and support patient education and self-management
Educate patients on medications and conditions, build self-management skills, and use motivational interviewing to promote behavioral change
Assess, triage, and respond to clinical changes potentially requiring emergency services
Collaborate with Community Health Workers and Social Workers
Meet regularly with local clinical site leaders and care management supervisor to triage program issues
Participate in local site operations and team meetings
Contribute to planning and growth of the program to meet MassHealth ACO needs
Facilitate interdisciplinary consultation through rounds, team meetings, and clinical reviews
Adhere to metrics, documentation, and workflow standards; maintain HIPAA confidentiality
Adhere to departmental/organizational policies and procedures
Care Manager must be available to work at the clinic site on assigned practice days in person
Qualifications Education Nursing degree: Diploma, ASN, or BSN/Masters (preferred). Ability to obtain BSN within 4 years
Certificates, Licenses, Registrations Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts AND/OR Completed an accredited 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 populations
Home care or clinic experience
Motivational interviewing
Clinical experience with patients having multiple complex health issues
Care management
Knowledge And Skills Excellent interpersonal skills and ability to work collaboratively
Self-management, prioritization, and patient-centered goal setting
Excellent written and verbal communication
Professional boundaries and ability to work with diverse, safety-net populations
Engagement of difficult-to-engage patients; rapport and trust-building
Creative problem-solving and adaptability to changes in healthcare delivery
Extensive knowledge of healthcare systems and community resources
Ability to leverage systems and resources for improved patient outcomes
Strong organizational and time management skills
Equal Opportunity Employer/Disabled/Veterans
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