General Summary:Conducts engagement, outreach and education activities for patients identified as requiring care coordination services. Routinely consults with the patient's PCP, specialist physicians as well as other members of the care team regarding high priority patients and the patient centered plans of care.Initiates telephonic or in person contact with eligible patients in order to conduct an initial assessment, patient/family health education, and develop a patient centered plan of care. This in person contact can be in the patient's home or in the physician practice.Incorporates previous knowledge of case management, payer rules and coverage, and utilization management principles to implement high quality cost effective care plans.Demonstrates excellent interpersonal skills when communicating with patients, families, and physicians in order to develop rapport, build trust, and engage patients in health promotion activities.Serves as a key resource to assigned patients, helping to proactively address their questions, concerns and care needs by guiding and facilitating access to providers and services.Influences appropriate utilization of health care resources by coordinating patient care, encouraging involvement in disease and case management programs and conducting follow-up care prior to and post interaction with the broader health care system including acute care admission, emergency department visits, specialist visits, and sub-acute care settings.As appropriate, directly provides ongoing care management services and/or refers patients to other care management programs.Communicates with other health care clinicians throughout the continuum about patient's care needs, utilization plan and applicable follow up plans.Using medical management criteria or other diagnostic screening criteria, collaborates with hospital staff to understand the appropriateness of hospital admissions and readmissions. Establishes a consistent schedule of communication and reporting with involved providers and the patient with intended goal of reviewing patient status and progress toward goals.Notifies primary care physician, care coordination management or practice leadership about over and under utilization of services as well as overall patient compliance with program goals.Collaborates with and seeks feedback from the program primary care physician, care coordination management team and Medical Director regarding challenging patient situations.Conducts case reviews at practice, program and /or care coordination meetings. Utilizes electronic medical record systems to document, monitor, and evaluate patient interventions and care plans.Keeps current with related trends in ambulatory care management including topics related to health education and coaching. Participates in regular meetings with care coordination management and leadership to review performance, patient caseload, special projects and programmatic goals.Provides information and education as necessary to other members of the care team regarding insurance benefit design and coverage, health care options and available community resources.Commitment to coaching (rather than teaching) patients to improve their health behavior to attain their health- related goals.Qualifications Minimum Requirements:Graduate of an accredited school of nursing.A registered nurse licensed to practice in MassachusettsBSN preferredCertification in case management (CCM) or other applicable professional certification.Minimum of 5 years experience in hospital, health plan or community case management or utilization management role.Previous experience working in a post acute setting such as LTAC, acute rehabilitation, skilled nursing facility, or homecare helpful.Previous experience working in an ambulatory setting such as a health center or physician's office is preferred.Managed care or previous health care reimbursement knowledge preferred.Knowledge of nationally accepted utilization review criteria such as Interqual and/or Milliman helpful.Evidence of continued education and professional development. Ability to travel to practices, patient's home, hospital or administrative offices. EEO Statement
The High Risk Patient Program Care Manager is responsible for establishing, implementing, monitoring and evaluating high cost effective care plans for a designated group of patients in the ambulatory setting. Utilizing a patient centered approach and directly interfaces with physicians, health care teams, patients and their care givers in managing the patient's care. The care manager needs sound clinical judgment, effective problem solving skills, critical thinking, excellent organizational and interpersonal skills, experience with team based care and the ability to multi task. They also need knowledge of available health services across the continuum, insurance benefit design and reimbursement methods, and experience in acute or community case management.
Locations include: BROOKLINE, JAMAICA PLAIN, MGH DOWNTOWN BOSTON PRACTICES
Principle Duties and Responsibilities:
Equal Opportunity Employer