Job Location:
Springfield, MA
Job Schedule:
Full Time
Standard Hours
40 / Exempt
Job Shift
Shift 1
Reports to: Senior Director of Clinical Integration
Shift Details
Mon-Fri
Job Description Summary
The Outpatient Nurse Care Manager is responsible for managing the complex patients that are included in the risk contracts. They are responsible for the management of care for this defined group of patients including complex care management, disease management, transitions of care, as well as coordination of care.
Major responsibilities include accurately identifying patients for care management, developing individualized plans of care, providing education, assessing/addressing barriers to care, medication reconciliation, medication titration as well as ensuring adherence to quality measures. The goal is to work with patients to optimize control of chronic conditions, improve functional status, reinforce self-management plan, and prevent/minimize long-term complications as well as to avoid unnecessary emergency room visits or hospital admissions. They will work collaboratively with providers and other health team members along the patient’s continuum of care and are available to patients and families for care coordination/education through face-to-face visits, home visits, if necessary, as well as telephonic interactions. In addition, they will assist with advance directives, palliative care, hospice, and other end-of-life care coordination. Appropriate documentation in patient medical records and/or care management application is required and is vital.
Care management program metrics including total medical expenses, emergency room utilization, hospital admission/readmission data will be reviewed on a regular basis to measure program impact. Assumes accountability for own professional practice and for aspects of patient care delegated to others. Practices within the ethical and legal parameters of nursing practice. This description covers the essential functions of the position. Incumbent is expected to perform other similar and related duties as assigned.
Adheres to system and department compliance policies, and all applicable laws/regulations.
Job Requirements
Responsible for coordinating and providing care that is safe, timely, effective, efficient, equitable, and patient-centered to the patients in the risk contracts.
Responsible for appropriately identifying patients for care management utilizing multiple sources including provider referrals, referrals from transitions of care, health plans as well as complex lists of patients from the ACO.
Conducts whole person assessments to determine individual patient needs and create individualized self-management plans of care in conjunction with the patient/family. Evaluate the effectiveness of the plan of care and revise as necessary to meet goals.
Assists patients to make informed decisions about their care by acting as their advocate regarding their clinical status and treatment options.
Promotes quality and cost-effective interventions and outcomes to patients in collaboration with primary care providers or specialists.
Manages transitions of care for patients discharged from the hospital, emergency room, or from a skilled nursing facility. Responsible for reviewing the discharge summaries, follow up on testing that is pending, ensure ordered services are in place. Outreaching to the patients to perform a medication reconciliation, ensure patients understanding of discharge instructions and assess for further care management needs.
Providing disease management/complex care management to patients face to face or telephonically as well as utilizing technology that becomes available. Providing home visits to patients, when appropriate. Titrating medications via protocols, when necessary.
Assisting with advance directives, referrals to palliative care/hospice when appropriate, and other end-of-life care coordination.
Overseeing population management activities with the Care Coordinators which includes addressing quality indicators that are out of range and assisting patients to reach targets.
Accountable for remaining current with knowledge of care management, including population management, availability of community resources and quality improvement methodologies.
Appropriate documentation in patient medical records and/or care management application is required and is vital. Care management program metrics including total medical expenses, emergency room utilization, hospital admission/readmission data will be reviewed on a regular basis to measure program impact.
Home visits as needed.
Assumes accountability for own professional practice and for aspects of patient care delegated to others.
Practices within the ethical and legal parameters of nursing practice.
Skills/Competencies:
Required: Strong communication, interpersonal and problem-solving skills to advocate for optimal patient outcomes. Capacity to work closely with patients, providers and their office staff and managed care plans. Strong organizational and prioritization skills. Attention to detail and able to perform work independently.
Qualifications
Minimally Required Education:
Associate degree Nursing
Preferred Education:
Bachelor’s Degree Nursing
Minimally Required Experience:
Minimum of 5 years’ experience as a Registered Nurse
Preferred Experience:
A minimum of 2 to 3 years of care management experience preferred.
License Required:
MA Registered Nurse
Driver’s License
Certification Required:
CPR
Why Choose Baycare:
BE HEALTHY, STAY HAPPY!
Baycare offers low-cost medical, dental and vision plans for all qualifying employees and their eligible dependents. Reimbursement for a variety of wellbeing activities, included but limited to gym membership and equipment, personal trainer, and massage.
SAVE FOR RETIREMENT
We offer a 401(k) Plan with employer safe harbor contributions to all eligible employees.
TIME TO RECHARGE
We respect the fact that our employees have lives outside of work, and we offer competitive PTO.
BE A LIFELONG LEARNER
Baycare has a tuition reimbursement program to support eligible employees who wish to continue their education to work towards increased professional responsibility and growth.
PEACE OF MIND
To help protect our employees, we offer fully company-paid life insurance as well as short- and long-term disability coverage.
WORK TOGETHER. PLAY TOGETHER
We work hard at Baycare, but we value fun and camaraderie outside of the office. Employees are invited to join in activities like fun runs for a charitable cause, summer barbecues, and our annual party.
FLEXIBLE AND FRIENDLY
Here at Baycare, we know that life doesn’t always go to plan. Our family-friendly office helps employees stay on track when life throws a curve ball.
REWARDING EXCELLENCE
We recognize that our employees are our greatest strength. From email shout-outs to performance bonuses, we make it a point to let our employees know how much we value their contributions.
We offer competitive total compensation that includes pay, benefits, and other recognition programs for our employees. The base pay range shown considers the wide range of factors that are considered in making compensation decisions including knowledge/skills; relevant experience and training; education/certifications/licensure; and other business and organizational factors. This base pay range does not include our comprehensive benefits package and any incentive payments that may be applicable to this role.
Equal Employment Opportunity Employer
Baycare Health Partner is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.
