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RN Care Manager (Float/Liaison), Commercial Care Management

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POST DATE 9/15/2016
END DATE 10/12/2016

Tufts Health Plan Watertown, MA

Watertown, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


Reporting to the Team Manager of Commercial Care Management Services; the Care Manager for Complex and Chronic Commercial Care Management Programs, works in a telephonic managed care setting. The CM combines strong clinical knowledge and critical thinking to facilitate a care plan that will ensure quality medical care for the chronic or medically complex member population; as well as members at risk for readmission serviced by Tufts Health Plan
The Care Manager RN, will demonstrate strengths in working independently as well as collaboratively within a team environment. The Care Manager will provide telephonic intervention to support members' medically complex members or members with chronic illness through comprehensive assessment to determine the member's specific opportunities for intervention. Based on national standards for case management practice, Care Manager will focus on empowering the member to support optimal wellness and improved self-management while advocating for the necessary medical services across the health care continuum. Key activities include facilitating program engagement, completion of evidenced based assessments to develop tailored member centered care plans, education on medical conditions, identification and coordination of needed medical services and resources. The CM will be evaluated based on standard productivity measures and benchmarks of the department.

An understanding of the benefit and network design for subscribers and dependents, is important to the success of this position. An understanding of the Tufts Health Plan Care Management Services Department business objectives and outcome measures is important to the accountability and success of the Complex / Chronic Condition Care Manager.


*Performs outreach to members for program introduction and engagement for participation.
*Assesses barriers to wellness, medical, behavioral health and psychosocial needs of the member using evidenced based assessments and care plan resources. Collaborate with member/ caregiver to coordinate post hospital discharge instructions. Develop individualized care plan including prioritized achievable health goals to improve, maintain or support optimal wellness. Collaborates with PCP to support physician plan of care.
*Implements the care plan using system tools followed by timely evaluation of member response to plan of care or attainment of goals and revises the care plan as indicated. Maintains timely telephonic contact with member/caregivers supporting progress toward goal achievement. Advocates for and coordinates medically necessary care within the parameters of the benefit design and available resources; compliments care plan with appropriate community services and resources.
*Performs case documentation according to Department, Regulatory and NCQA standards including but not limited to timely opening and closing of cases and real time case data entry.
*Facilitates/collaborates with utilization management process within jurisdiction according to approved time frames, department and regulatory standards.
*Attends 1:1 meeting with Team Leader as defined by the department, as well as, attends regularly scheduled Department, Company, educational or other required meetings as necessary.
*Maintains compliance with Corporate Communication Policy, Professional Code of Conduct, and Department communication standards. Maintains compliance with Corporate Compliance Policies and periodic trainings

*Demonstrates the following abilities to support care plan development: Ability to access and interpret member benefit plan information; and knowledge of funding resources, support services, clinical standards and outcome measures.
*Meets department, regulatory or compliance performance thresholds evidenced by quarterly audit and achieves development goals as developed within the performance appraisal
*Demonstrates understanding of department business goals and relationship to the overarching business objectives of Tufts Health Plan.
*Performs additional duties to support department as requested

Registered Nurse with current unrestricted state license required.
Bachelor's in Nursing is preferred.
National Certification in Case Management is highly desirable.

EXPERIENCE: (Years of experience)
Minimum of five years of clinical nursing experience; (medical, oncology, neurology, surgical, other specialties)
Experience in medical case management highly desirable
Experience in chronic condition /disease management is highly desirable
Experience in extended care planning highly desirable (discharge planning to Rehab, SNF, home care, hospice); Experience in obstetrical nursing required for Health Birthday complex care manager for at-risk pregnancy program.
Experience in pediatric nursing required for pediatric complex care manager supporting Priority Care program Proficiency in a second language is highly desirable.

SKILL REQUIREMENTS: (Include interpersonal skills)
*Address multiple complex issues throughout the workday in a flexible professional manner.
*Identify emergency situations and follow the appropriate protocol
*Prioritize work to meet the needs of the member, the Department, and Tufts HP Corporate
*Knowledge and experience in effective case management interventions and strategies across populations
*Demonstrate strong clinical and critical thinking abilities
*Excel in positive relationship building.
*Effective listening skills, written and verbal communication abilities
*Skilled negotiator
*Perform critical analysis, plan, organize, promote client family autonomy
*Proficiency with or ability to learn technology programs such as Microsoft Word and Excel; other programs as needed
*Proficiency with or ability to learn technology for initiating and participating in web based communications: webinars, instant messaging, slim client, soft phone or others

Interpersonal skills:
*Ability to perform job functions with autonomy
*Ability to collaborate with team members including utilization care manager, behavioral health CM, transition of care managers, medical providers, care coordinators, department management on job expectations and outcomes
*Must possess excellent interpersonal skills with an understanding of differences between the need to promote change while maintaining positive rapport with members, family members, and providers.
*Must develop and maintain positive communication to promote managed care philosophy
*Must have commitment to excellence in customer service

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime)
*Fast paced office environment handling multiple demands.
*Position has opportunity for remote work as defined by the Director of Commercial Care Management
*Must be able to exercise appropriate judgment when necessary.
*Must be able to work and communicate with customers in a telephonic office environment

CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled


Founded in 1979 as a non-profit health maintenance organization (HMO), Tufts Health Plan is one the country's largest HMO offering a full array of healthcare coverage options to individual consumers and employer groups. Tufts Health Plan has received high marks for its quality from a variety of third parties including U.S News & World Report and Newsweek.