September 08, 2016
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SNF/LTC RN Care Manager

Tufts Health Plan - Watertown, MA

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  • Company
    Tufts Health Plan Tufts Health Plan
  • Location
    Watertown, MA
  • Job Type
  • Job Classification
    Full Time
  • Experience
    Mid-Career (2 - 15 years)
  • Education
    Bachelors Degree
  • Company Ref #
  • AJE Ref #

Job Description

Under the administrative direction of the Clinical Manager, the Nurse Case Manager (NCM) for Senior Care Options (SCO) is responsible to manage all aspects of member care for a panel of frail elderly, while working within a healthcare team. The NCM directly interfaces with physicians, other members of the primary care team, members, and their caregivers in identifying risk factors, conducting assessments, and developing and implementing care plans to comprehensively manage their members' care.


The NCM will have a clear understanding of the role and will demonstrate a commitment to executing on the following responsibilities:

- Timely completion of initial and ongoing geriatric assessments
- Development and communication (with member, caregiver and primary care physician/primary care team) of an individualized plan of care
- Completion of the Minimum Data Set-Home Care (MDS-HC)
- Facilitation of member and caregiver access to community resources relevant to the member's needs, including referrals to Adult Day Health, Adult Foster Care and the Personal Care Attendant Program.
- Participation in routine primary care team meetings
- Pro-active management and follow-up (via home visits and by telephone) according to the member's care plan
- Management and coordination of all transitions of care, including:
- Communicating care plan to providers in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care) and ensuring providers receive timely clinical data that may impact healthcare treatment decisions
- Direct caregiver support
- Serves as a member advocate and facilitator to resolve issues that may be barriers to care
- Provide education and coaching to the member, family, and/or caregiver about health status, treatment options, goals of care, and health insurance benefits to assist members in making the most informed decisions and help promote self management

Education Requirements:
Bachelors of Science in Nursing (BSN) and Registered Nurse with current, unrestricted state licence is required.

* Minimum 3 years clinical nursing experience required
* Experience in case management managing geriatric/chronic illness populations required
* Experience within a SCO program highly preferred
* Experience in Medicare and/or Medicaid managed care preferred
* Proficient in computer use, the Internet, and health information technology required
* Case management certification a plus

Skill Requirements:
* Work cooperatively as a team member across multiple levels within the organization
* Demonstrate initiative in achieving individual, team, and organizational goals and objectives
* Must be able to prioritize work and develop strategies for adapting to constantly changing priorities and urgencies.
* Regard for confidential data and adherence to corporate compliance policy
* Demonstrate cultural competency and sensitivity
* Demonstrate the ability to work autonomously

Other Requirements:
* Ability to travel frequently to member's homes, hospitals, skilled nursing facilities, PCP office practices and other sites where patients receive care.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled