RN CARE MANAGER- Population Health Management Integrated Care Management Program

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POST DATE 8/13/2016
END DATE 11/10/2016

Massachusetts General Hospital(MGH) Boston, MA

Boston, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Entry Level (0 - 2 years)
Bachelors Degree


MGH is part of a broader Partners network that is providing Population Health Management for both Medicare and Commercial Insurance high risk, medically complex patients. The project staff is involved in designing a program that results in providing care to high-risk, medically complex patients across the continuum. The position requires a high degree of flexibility, independence, and willingness to participate in multiple activities and provide support to all members of the project team. The position must have strong communication skills and the ability to converse comfortably with patients and their caregivers, practice staff and program staff and administration. The Care Manager would work with the program staff to ensure eligible patients are receiving the services they need to achieve an optimum quality of life.

The Care Manager, as a member of the health care team is imbedded in the Primary Care Practice. The role collaborates to enhance the delivery of patient care services along the continuum of care. The Care Manager meets patients needs efficiently and expeditiously by continuously improving the patients experience, helping to ensure the institutional standards of high quality patient care, reducing cost and ensuring reimbursement. Through broad knowledge of clinical care and systems management, the Care manager evaluates, predicts, and facilitates the trajectory of patient care.
The model has a Care Manager panel ratio of approximately 1/200 patients. The care is supported by a team that includes Social Worker, Pharmacist and Community Resource Specialists.
Principle Duties and Responsibilities
Performs a comprehensive nursing/psycho- social assessment on a targeted patient population as defined by MGH/MGHPO and contractual constituents.
Identifies key barriers to care and patients ability to manage their health and wellness through initial and on-going assessments.
Develops a comprehensive plan of care in conjunction with the patients PCP.
Implements a plan of care, appropriately utilizing the menu of services for patients, as well as, insurance approved, community and practice-based and MGH services.
Ensures the timely implementation of the plan of care.
Ensures that all elements critical to the plan and trajectory of care have been communicated to the patient/family and members of the Interdisciplinary Team.
Monitors the patients progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused and friendly, high quality, efficient, and cost effective
Monitors patients in Non-Acute facilities in collaboration with the iCMP Care Team.
Documents in the medical record as appropriate, as part of the Interdisciplinary team.
Identifies patients/families with complex psychosocial and non-medical discharge planning issues, refers to iCMP team, as appropriate
Assesses patient/family continuing care needs in collaboration with the interdisciplinary team in the review/revision of the therapeutic plan to expedite and arrange non acute care.
In collaboration with iCMP team, monitors the patients progress and plan of care with the aid of internal and external utilization and quality guidelines. Identifies, documents, and reports issues and system barriers.
Complies with Care Management Standards of Practice, based on assignment.
Evaluates, coordinates, manages and documents all activities related to clinical approval/denial processes and communicates relevant information to patients/families, members of the multidisciplinary team, hospital departments, and payers.
Participates in On Call coverage per Department guidelines.
Performs other duties as assigned.
Job Elements
Facilitates access to the health care delivery system along the continuum,
by navigating any barriers to care and advocate on the patients behalf.
Acts as the liaison by consulting and collaborating with members of the health care team including Inpatient Care managers, practice-based staff, and other provided to promote continuity of care as patient move through the continuum.
Promote wellness and patient self- management.
Collects data as designed by the projects for ongoing analysis.
Participate in practice-based Medical Management meetings, as appropriate.

RN with current license to practice in Massachusetts.
Bachelors degree strongly preferred.
Minimum of 1 year nursing experience required.
Acute hospital experience preferred.
Related Care Management experience preferred
Strong assessment and problem solving skills.
Strong interpersonal skills.
Ability to work independently with minimal supervision.
Goal oriented and accountable.
Demonstrated organizational skills.
Demonstrated ability to work in a complex setting.
Ability to work in an interdisciplinary team based environment.
Strong oral and written communication skills.
CM Certification desirable
Strong Computer skills

Massachusetts General Hospital is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. Applications from protected veterans and individuals with disabilities are strongly encouraged.