Complex Care Manager 7/21/2018
BMC HealthNet Plan
JOB DESCRIPTIONAPPLY COMPLEX CARE MANAGER
About the Program:
It s a new day in healthcare. We are proud to participate in Massachusetts reform of the state s Medicaid program, MassHealth, and have partnered with hospitals, health systems, and community health centers across the state to form Accountable Care Organizations (ACOs). This will give those communities facing tough health and socioeconomic challenges a new way to access the care they need.
To learn more about our program, visit us at jointheadventure.bmchp.org
There s nothing ordinary about our Complex Care Manager role after all, complex is in the job title. We thrive on finding solutions for the most difficult health challenges that occur in our communities; conditions that unfortunately affect too many of us, from substance use disorder to mental illness. What sets us apart is our commitment to going above and beyond entering into the homes of people and working with them to improve their quality of life.
It s truly a team effort working with community partners, caregivers, social service agencies and others to develop a comprehensive approach for clinical and non-clinical support. We recognize this is a big undertaking, but we understand there s a huge reward in improving patient satisfaction, decreasing medical costs and so much more.
Now is the time to change the way communities that we serve access healthcare. If you won t rest until you see results and believe that anything is possible, we re the place for you.
Clinicians in this position will work in one of 3 programs: Primary Care-based Complex Care Management, Readmissions Care Team, or ED-based Complex Care Management. Clinicians will work at a designated site of care and, depending upon the program he/she is a part of, will work in either a Primary Care Practice (PCP), Emergency Department (ED), or Inpatient (IP) setting.
Sample of Key Responsibilities:
* Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leaders
* Ability to execute core care management duties:
* Comprehensive assessment: bio-psycho-social-spiritual
* Collaboration with patient and care team to develop patient-centered care plan
* Focus on chronic disease management, social determinants, transitions of care and advanced care planning
* Implementation of care plan
* Collaboration with community partners, such as VNA agencies, caregiver programs, DME providers and social service agencies
* Assessment of goal completion, with transition of patient to inactive or graduated status as appropriate.
* Uses 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 hospital
* Meet the patient where he/she is; observe the patient without intervention or judgment
* Has 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
* Supervises and delegates assignments to Community Wellness Advocates and/or Patient Navigators or Social Workers and follows up on completion. Manages staff performance through the following:
* Tracks individual performance metrics
* Provides one-on-one supervision to each team member on a regular basis
* Consistently available for timely consult regarding patient matters during business hours
* Develops on-boarding curriculum in collaboration with leadership
* Facilitates access to appropriate training and educational resources
* Facilitates access to appropriate supportive and psychosocial resources
* First point of contact for corrective/disciplinary matters as needed.
* Meets regularly with leaders at the local clinical site and Manager of Accountable Care Transformation and Care Management 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.
About our Ideal Candidate:
* Associates or Bachelor s Degree in Nursing required
* Active license to practice as a Registered Nurse or Nurse Practitioner in Massachusetts
* A minimum of two years of clinical experience
* Prior experience working with vulnerable and/or Medicaid populations, home care setting, clinic setting or patients with multiple complex health issues
* Prior experience in care management or motivational interviewing. Skilled at engaging difficult to engage patients ability to build rapport, trust
* Fluency in Spanish and/or Haitian Creole is a plus
Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. BMC HealthNet? Plan/Well? Sense Plan participates in the E-Verify Program to electronically verify the employment eligibility of newly hired employees.