A career at AllWays Health Partners is you in every way! Inspired by our affiliation with Partners HealthCare, our promise as a people-first organization starts with our employees. Get inspired to bring your unique talents to our diverse community and challenge the health care industry status quo with innovative programs that put people first. Our perks include a competitive benefits package, access to world-class doctors, and more.
The Community Based are Manager (CBCM) will use clinical and CMSA standards to provide care management for identified AllWays Health Partners members in the Your Care Circle program. The CBCM carries a caseload of members identified for inclusion in the Care Circle program. The Care Circle model is a mobile, face-to -face community model in which work with members will be primarily conducted in person, meeting members in their home, family home, shelter or other agreed upon public space.
The CBCM works closely with other Care Circle team members including social care managers, medical and behavioral health care managers, community health workers, clinical support coordinators, medical director and associated consultative professionals such as pharmacist, rehabilitation specialist, recovery coach, etc. In addition, the CBCM will work closely with other AllWays Health Partners departments to ensure quality and effective service and support to these members. This position will initiate and maintain communication with members, Primary Care Clinicians and other health team members regarding care management plans to collaborate to meet members' needs.
Completes comprehensive bio, psycho-social assessments of members and their families for all product lines, including Medicaid, Commercial and Connector product lines.
Creates comprehensive patient-centered and culturally competent care management plans to include problem identification, goal-setting, interventions and expected outcomes, with the input of the PCP, specialists, members, and other team members as appropriate.
Facilitates and coordinates the appropriate services and supports to meet the needs of the Care Circle members.
Educates members related to health care conditions and treatment plans with a focus on medication adherence, appropriate use of emergency room, self-care and navigation of the health care system.
Works collaboratively with other Care Circle Team members, community health workers, physicians and other consultative professionals to achieve goals, such as:
o Decreasing acute events
o Eliminating or reducing social determinants
o Increasing medication and treatment adherence
o Improving member engagement in care
o Increasing coordinated care in appropriate settings
o Improving the member's quality of life. Participates in member/family meetings and health appointments.
Participates in rounds forums to promote integrated case discussions and problem-solving.
Documents care management activities in AllWays Health Partners' care management system according to established protocols.
Demonstrates flexibility and creativity in order to achieve maximum effectiveness and optimal outcomes for members and their families.
Provides assistance, advocacy, and support to members in an effort to achieve optimal health with a focus on reducing or eliminating social determinants.
Collaborates with all treating providers and monitors members closely when they are receiving inpatient treatment.
Ensures timely post-discharge follow up to conduct medication reconciliation and coordination of services and needs to reduce post-discharge complications and re-admissions.
Participates in orientation of new staff.
Anticipates and exceeds internal and/or external customer expectations and requirements; and establishes and maintains effective relationships with customers.
Manages special projects as needed.
Other duties as assigned with or without accommodation.
Working Conditions and Physical Effort:
Work is conducted in the community: home visits and visits in public spaces.
Works remotely when appropriate.
Travel is required. When not traveling, can work remotely from home.
Will be required to attend weekly meeting on site and other virtual meetings as applicable
Valid Unrestricted Massachusetts RN or other Health Care professional license
Certified Case Manager (CCM) or other comparable certification This certification is required but may be obtained within 6-12 months of hire.
3-5 years acute care or program-specific population/disease expertise
5-7 years of directly related professional experience
Excellent verbal and written communication skills
Demonstrated ability to multi-task
Works with minimal or direct supervision
Ability to work independently and in teams
Demonstrated creativity in formulating care plans from assessment and clinical information
Use of evaluative and outcomes data to improve ongoing care management services
Promotion of health care outcomes in concert with currently accepted clinical practice guidelines
Adherence to the code of ethics for the care manager's professional discipline
Development and maintenance of collaborative, proactive and patient focused relationships to maximize client health care outcomes
Strong internal and external customer orientation and focus
Ability to build collaborative working relationships with practices and facility personnel
Demonstrated commitment to member advocacy
Participation in quality improvement initiatives within the Clinical Operations Department
Competency with Windows based systems, Microsoft Office applications and web-based searches
Competence in or ability to learn ALLWAYS HEALTH PARTNERS care and utilization management systems and tools
Care Management practice will be guided by ethical principles and integrity
Demonstrate AllWays Health Partners' core brand principles of always listening, challenging conventions, and providing value.
Bring fresh ideas forward by listening to and working with employees and the people we serve.
Strong aptitude for technology-based solutions.
Ability to inject energy, when and where it's needed.
Respect the talent and unique contribution of every individual, and treat all people in a fair and equitable manner.
Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.
Be accountable for delivering high-quality work. Act with a clear sense of ownership.
Bring fresh ideas forward by actively listening to and working with employees and the people we serve.
Certification or Conditions of Employment:
Pre-employment background check
CORI background check
Valid Massachusetts driver's license
Must be able to work independently and in teams. Works with minimum supervision, conferring with manager only on unusual matters.
Senior level professional with extensive internal and external interaction.