It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.
Job Summary:
The Complex Care Manager provides holistic care management services for members throughout the continuum of care by assessing the member clinically as well as member’s readiness to make behavioral changes and actively participate in a care plan, establish goals and meet those goals. Wellsense Health Plan members may include those who have chronic conditions and complex care needs, including those considered to be the highest risk members, those who are homeless, undergoing organ transplantation, have multiple clinical and behavioral co-morbid conditions, and with special health care needs. The clinician works collaboratively with a multidisciplinary team (both internal and external) including providers, our clinical vendor partners (behavioral health, pharmacy, etc.) and community/ State agencies to increase patient knowledge, motivation, and compliance with treatment through targeted interventions that address the member’s holistic needs from a medical and psychosocial/socioeconomic standpoint. Following this approach, the goal is to improve member health outcomes and decrease overall cost while improving the member’s overall experience with the health care delivery system.
Utilizing both telephonic outreach and face to face member visits and through the use of assessments, real-time data, motivational interviewing techniques and evidence-based practices, the Complex Care Manager engages with the member and the multidisciplinary team to develop an Individual Care Plan (ICP) that emphasizes self-management goals, care coordination, psychosocial, socioeconomic, and community-based supports and on-going monitoring and appropriate follow up. The Complex Care Manager identifies and addresses barriers to optimal self-management and works with the member, their support persons, and team to coordinate care throughout the health care continuum, assisting the member to access all available benefits and resources including family support and community resources, with a goal of promoting appropriate utilization of services at the appropriate level and site of care such as preventing ambulatory sensitive emergency department visits and inpatient admissions, avoiding readmissions, and encouraging the member to keep scheduled outpatient appointments to include preventive care visits. The Complex Care Manager may meet members in their homes, shelters, provider offices, medical facilities, and at locations agreed upon with the member. Travel required up to approximately 50% of the time throughout Hampden or Worcester Counties. A valid driver’s license and regular access to a reliable vehicle is required to perform face-to-face visits
Our Investment in You:
Key Functions/Responsibilities:
- Supports programs and clinical best practices with the objective of improving health outcomes, preventing hospital readmissions, improving member safety and reducing medical errors, and promoting health and wellness activities, where appropriate.
- Completes a targeted general assessment and applicable condition specific assessments.
- Evaluates members’ need for complex care management, disease management or chronic condition management.
- Collaboratively develops an individual care plan with the member focusing on the member’s goals and objectives, identifying strategies, supports and/or services needed to achieve short and long term goals.
- Identifies and addresses barriers to optimal self-management and works with the member and team to coordinate care throughout the health care continuum.
- Assists the member to access all available benefits and resources including family support, community resources, and when applicable, school-based services.
- Utilizes motivational interviewing techniques to engage members in care management and to coach members regarding health promotion, disease management and preventive health strategies.
- Uses real-time data from electronic medical records, where available.
- Uses Wellsense Health Plan reporting to access member medical and pharmacy utilization reports, sharing with PCP, to promote medication compliance and action plans.
- Supports and enhances the member’s capacity to self-manage.
- Evaluates the effectiveness of the care management provided to the member on an on-going basis and updates the ICP accordingly.
- Utilizes evidence-based practices and guidelines to educate members on specific disease processes.
- Provides or arranges for resources necessary to meet members’ social determinants of health care needs including but not limited to psychosocial and socioeconomic needs.
- Promotes and encourages member collaboration with the primary care provider and other health care providers.
- Completes documentation in the medical management information system real-time during face-to-face meetings, by phone, and in a timely manner and in keeping with contractual requirements, internal policy and NCQA accreditation standards. Facilitates multidisciplinary consultation on members’ behalf through participation in rounds, team meetings and clinical reviews.
- Conducts face-to-face visits with members and providers, community and state agencies, as appropriate.
- Regular and reliable transportation and the ability to conduct face-to-face appointments with members, providers, community and state agencies
- Assists with staff training and mentoring.
- Refers cases to additional internal or external care management services, as clinically indicated.
- Consults with and refers members to the multidisciplinary team, as appropriate.
- Coordinates member care transitions through collaboration/communication with multidisciplinary care team as well as pre-admission assessments, post-discharge assessment and follow-up to ensure appointment is made with the PCP or Specialist; assessing for home health services, DME needs, and transportation issues; performing medication reconciliation; ensuring compliance with discharge plan, appointments and medication regimen.
- Uses available standardized educational materials in an appropriate reading level and language to educate members about their conditions.
- Monitor members’ labs, tests results, appointments and other data in order to best coordinate care utilizing EMR (where available and appropriate) and the Plan’s care management software.
- Maintains HIPPA standards and confidentiality of protected health information.
- Demonstrates strong knowledge of contractual requirements of all Wellsense products and provides cross coverage across product lines when needed
- Adheres to departmental/organizational policies and procedures.
- Other duties as assigned.
Supervision Exercised:
Supervision Received:
- Regularly scheduled meetings with Manager of Care Management
Qualifications:
Education Required:
- Bachelor’s degree in nursing or Associate’s degree in Nursing and relevant work experience.
Experience Required:
- 3 years related experience in home health care or managed care organization
- 3 years clinical experience with members who have multiple, chronic or complex health conditions
- 2 years’ experience in care management, care coordination and/or discharge planning
Experience Preferred/Desirable:
- Experience working with Medicaid recipients and community services
- CCM certification preferred
- Experience with FACETS, JIVA, InterQual or other healthcare database
- Experience delivering care for pediatric populations, particularly children with asthma and neurodivergent disorders (e.g., autism spectrum disorder), strongly preferred
- Experience navigating and coordinating with school systems, including familiarity with IEP and 504 plans, strongly preferred
Required Licensure, Certification or Conditions of Employment:
- Successful completion of pre-employment background check
- Current unrestricted, applicable, state license to practice as a Registered Nurse in Massachusetts.
- Regular and reliable transportation and the ability to conduct face-to-face appointments with members, providers, community and state agencies
Competencies, Skills, and Attributes:
- Strong Motivational Interviewing skills
- Strong oral and written communication skills
- Ability to effectively collaborate with health care providers and all members of the multidisciplinary team
- Strong technical skills and ability to document in the Plan’s care management documentation system in real-time when meeting with members and providers in-person or by phone.
- Demonstrated organizational, time management, and prioritization skills
- Able to work in a fast paced environment with competing priorities, ability to adapt to team and organizational changes.
- Experience with Microsoft Office application, particularly MS Outlook and MS Word, Excel and other data entry processing applications
- Strong analytical and clinical problem solving skills
Working Conditions and Physical Effort:
- Travel required up to approximately 50% of the time throughout Hampden or Worcester Counties
- A valid driver’s license and regular access to a reliable vehicle is required to perform face-to-face visits
- No or very limited physical effort required. No or very limited exposure to physical risk.
- Regular and reliable attendance is an essential function of the position.
- Work may be performed in a typical interior/office work environment or in a home office except when conducting face-to-face visits.
- Face-to-face visits may be conducted in a member’s home, shelters, physician practices, hospitals, or at a mutually agreed upon location between the member and the care manager and also with community and state agencies, as appropriate.
Compensation Range:
$74,000 - $107,000
This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.
Note: This range is based on Boston-area data, and is subject to modification based on geographic location.
About WellSense
WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.
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. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees
