In collaboration with other members of the healthcare team, Complex Care Managers work with some of our most challenging patients who are at the highest risk for health exacerbations. This role is based in the primary care setting but interacts with the entire health system and network partners. Complex Care Managers are accountable for organizing and coordinating services for patients who are most at risk for health deterioration, sentinel events, and/or poor outcomes.
Development of a tracking system for patient care coordination and care management across the continuum, including care transitions, referrals, report management, and two-way communication between the PCP, specialists, and other providers.
Integration of the patient/family into care coordination and care management planning and communications, assuring that the patient/family are informed and supported in decision-making.
Transition care for patients discharged from the hospital within 24 – 48 hours to prevent readmission and related complications.
Evaluation of and appropriate follow-up care for patients seen in the Emergency Department to prevent further disease exacerbation, untoward complications, or additional ED or hospital utilization.
Evaluation of payer-based high risk patient lists to determine patients at highest risk for health deterioration, sentinel events, and/or poor outcomes.
Management of patients identified by the PCP team as highest risk.
Care management of highest risk patients to reduce risk, decrease hospital and ER utilization, and improve outcomes.
Maintenance of a care management registry for documentation of highest risk patients, care management interventions, and care plans.
Timely and ongoing communication with the PCP and practice team to identify highest risk patients and to maximize the management of patient needs and related risk reduction.
Coordination of care with other care managers both within the primary care and in the larger system (i.e. - home health care, payer case managers, etc.) and with specialists to maximize care and promote patient safety.
Oversight of the care coordination system for high risk and high utilization patients that is managed by the practice team
- Graduate of an NLN-accredited School of Nursing. BSN required.
- Current RN license in the Commonwealth of Massachusetts Certifications: Case Management or equivalent certification (highly desired)
- Minimum of 5 years of broad clinical experience, predominately in community health nursing, VNA, or home care.
- Care Management Experience required.
- Extensive knowledge of chronic disease management.
- Comfort working with patients with behavioral health and substance abuse co-morbidities and patients requiring considerable support accessing community-based supports.
- Demonstrated competency in managing a caseload of ethnically diverse patients across the continuum of care.
- Bi-lingual capacity (Spanish, Portuguese, Haitian Creole) highly desirable.
- Ability to travel to and move around outpatient care areas, patient homes, inpatient settings, and skilled nursing facilities to meet with patients, families, and medical personnel.
- Ability to read and write accurately and effectively in a medical chart.
- Ability to perform telephonic care management
- Driver's License and car ownership required.
- Ability to collaborate with other disciplines both in and outside of CHA.
- Ability to maintain effective working relationships with clinic staff, outside agencies, payers, and patients/ families of a diverse and multicultural population.
- Comprehensive nursing assessment, problem identification, and care plan development. Disease management, screening for developmental issues, depression, other psychological conditions, and frailty.
- Clinical system design and development
- Project management
- Behavioral strategies including motivational interviewing and self-management support
- Relationship building with patients, staff, and providers
- Management of staff
- Documentation in an EMR
- Computer skills including excel, word, and PowerPoint