Hiring for an ACO Nurse Care Manager in Methuen, MA
Monday thru Friday 40 hours/week (day shift)
Pay rate: $40-43/hr
Position Summary:
As an integral member of the care management team, the Nurse Care Manager (CM) will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic conditions, many of whom also face multiple barriers in their lives which makes it difficult for them to achieve the self-care required to improve their health and well-being. This position requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in person in a variety of potential settings such as but not limited to, the health center, community, home, or an inpatient facility.
Job Responsibilities and Performance Standards:
- Conduct Comprehensive Assessments on all patients referred into the complex care management program and formulate individualized care plans based on the patient’s needs and preferences.
- Implement interventions and revise care plans as needed based on ongoing patient assessment and evaluation, including following any inpatient discharge or ED visit.
- Facilitate patient outreach to assess the patient’s progression toward their goals.
- Use motivational interviewing strategies to optimize patient engagement.
- Engage members and caregivers in active care planning with focus on medical, behavioral, social, member-centered care needs.
- Coaches and guides member/representative to meet bio/psycho/social goals.
- Contribute to PCMH (Patient Centered Medical Home) care team meetings as needed and is an active member of the PCMH team.
- Conduct medication assessments and reconciliation as appropriate and refers to the care team pharmacist as needed based on assessment.
- Provide care coordination, which may include but not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.
- Facilitate case conferences as needed, including engaging community partners and other community-based stakeholders who are engaging with patients.
- May be required to meet patients while they are inpatient to provide education and support about the discharge process and transition members into care management.
- Assess the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support including symptom response plans based on the member’s needs and preferences.
- Refer/connect patients with primary care, behavioral health, flexible services, community partner, respite, and other community based social services as indicated and appropriate.
- In collaboration with Community Health Workers, create and maintain a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services.
- Participate in the integrated care team meetings and rounds as required.
- Maintain accurate, timely documentation in electronic systems including health center EHRs.
- Provide coverage for team members who are out of office.
- Maintain patient caseload based on internal standards. ? Other duties as assigned.
Qualifications and Experience:
- Licensed Practical Nurse (LPN) with Care Management experience, ASN (Associate degree in Nursing) or bachelor’s degree in Nursing (preferred).
- Current, active MA Nurse license.
- Case Management Certification (CCM, ANCC RN-BC), preferred.
- 3-5 years of nursing experience, preferably in-home health, ambulatory care, community public health, case management, coordinating care across multiple settings and with multiple providers.
- Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Pharmacists, Social Workers, Community Health Workers, and other health care teams.
- Ability to flexibly utilize clinical expertise to solve complex problems.
- Experience working with patients with chronic and behavioral health needs.
- Must be flexible and adaptable to change.
- Demonstrate the ability to work independently.
- Must demonstrate excellent interpersonal communication skills.
- Additional qualities that would be a good fit for our team include: Enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a ‘go with the flow’ mentality.
- Experience using appropriate technology, such as computers, for work-based communication.
- Experience and proficiency with Microsoft Office and online record keeping.
- Experience within the ACOs member population preferred including Medicare/Medicaid.
- Experience working with Federally Qualified Health Centers, strongly preferred.
- Demonstrated experience working with diverse patient populations and workforce.
- Valid driver’s license.
Physical Environment
- Physical surroundings are satisfactory with occasional exposure to injury or unpleasant elements such as chemicals or infectious hazards which require precautions.
Social/Psychological Conditions
- Occasional mental stress due to situation and workload pressure.
Physical Effort
- Frequently sits, stands, walks, bends, reaches, and stoops throughout the workday.
- Frequently lifts, pull, push and carry up to 20 lbs.
- Periodic eye strain.
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