RN, Care Manager

Greater Lawrence Family Health Center Lawrence , MA 01842

Posted 3 months ago

Established in 1980, the Greater Lawrence Family Health Center, Inc. (GLFHC) is a multi-site, mission-driven, non-profit organization employing over 600 staff whose primary focus is providing the highest quality patient care to a culturally diverse population throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program..

GLFHC is seeking a Registered Nurse Care Manager (RNCM) to join our team!

Under the leadership of the Manager of Care Management, the primary function of this position is the care management and care coordination of medically complex patients considered high risk/high cost, as part of the Merrimack Valley ACO's overall medical management strategy. To accomplish this, the RNCM works in collaboration with clinicians as an integral health care team member to assist in managing the care of patients who are covered under the My Care Family contract across the healthcare continuum. The NCM supports the MVACO PCPs in improving their health-related quality scores.

The goals of nurse care management are to promote/improve optimal health by effectively managing resources, reducing unnecessary utilization of health resources such as hospital admissions, readmissions, emergency room visits and unnecessary services. Patients are identified for care management through predictive modeling, physician referral, and other caregivers. Once identified, patients receive an initial home/practice face to face, or telephonic comprehensive assessment by the NCM for the purpose of developing an individualized care plan. Care plans focus on transitions of care, coordination of home services/resource, education in self-management of chronic conditions, and attention to the psychosocial needs of the patient and their caregivers. The RNCM will assess patients for social determinants of health that could result in high utilization of healthcare services and/or affect the patients' ability to actively participate in management of their health care. In addition to providing telephonic support, the RNCM may attend care planning meetings at the PCP practice, hospital, SNF or rehab. A web-based software program is used to monitor patients progress and document care plans. The assignment of the position includes working with one or more clinical sites and/or physician group practices. The RNCM is expected to carry a caseload of approximately 45-75 patients. The incumbent will be proficient in understanding, NCQA and PCMH requirements.

Job Responsibilities and Performance Standards:

  • Perform Comprehensive Assessments on all assigned enrollees identified as having Special Health Care Needs through Care Needs Screenings, claims, risk stratification, patterns of utilization, clinician referrals, and enrollee self-referrals, within the timeframes established by MassHealth. Patients may also be identified by admission, transfer, discharge reports, and quality reports (disease management).

  • Develop a person-centered care plan that meets MassHealth requirements and is approved by the enrollee or enrollee's designee and the enrollee's Primary Care Physician (PCP).

  • Supports patients through the coordination of care for designated high-risk patients at specific assigned site/s or for specific disease process/es.

  • The RNCM will carry an average caseload of 75 patients per month based on acuity. Patient's average length of stay in the program will vary depending on the individual patients needs. Patients who are requiring disease management, transitions of care management, and post acute utilization management, and quality management will have shorter length of stay than those patients who require longer term care management.

  • Supports patients through the coordination of care for designated high-risk patients at specific assigned site/s or for specific disease process/es.

  • Assess patient progress toward goals based on clinical judgment, review of patients self-monitoring tools, and trends in clinical data.

  • Provide face-to-face care management, including but not limited to: home visits, office visits with PCP and/or specialist. The RNCM will additionally work in collaboration with the hospital staff and Navigator(s) to coordinate transition of care. Telephonic care management may be provided when face-to-face care management is not possible, needed, or desired by the enrollee.

  • Ensures the development of patient centered care plans, and maintains constructive relationships between, care coordination staff with staff from all interfacing department staff.

  • Demonstrates compassion and respect for assigned enrollees and their families.

  • Establish trusting relationships with assigned enrollees and their families.

  • Accountable for the care outcomes of all assigned enrollees.

  • Participate in ongoing quality improvement activities related to individual, team, and organizational performance improvement.

  • Utilizes ascribed processes for managing the needs of complex patients, initiating interventions based on physician approved patient-specific protocols and order sets (i.e. immunizations, consults age-appropriate preventive screening such as mammograms, colonoscopy, smoking cessation counseling).

  • Contributes to the documentation of individualized care plans for identified patients focusing on specific treatment goals. Regular and routine travel between clinic sites, patient homes, and to community facilities will be required with occasional travel in inclement weather.

  • Review data and trends from MVACO reports to determine system performance related to enrollee health outcomes and suggest areas for improvement in relation to care management activities.

  • Serve as expert consultant on medically complex care management to the MVACO care team (including the PCP).

  • Serve as primary care team liaison to Long Term Social Supports Community Partners.

  • Serve as primary care team liaison to state and local social service agencies.

  • Accountable for the care outcomes and total medical expense of all assigned enrollees.

Requirements Minimum of two years nursing experience with 6 months of case/care management experience within a physician practice, acute care hospital or home care preferred. CCM preferred.

  • Prior experience in a Patient Centered Medical Home, NCQA, strongly preferred.

  • Familiarity with computerized data management and research protocols.

  • Sound analytical and computer skills required.

  • Strong verbal and written skills required.

  • Bilingual, English/Spanish required.

Education

  • Graduate of an accredited professional nursing program with current Massachusetts Registered Nurse license. BSN preferred.

Apply On-line Send This Job to a Friend

  • Programs & Services

  • For Patients

  • The Family Pharmacy

  • Locations

  • Family Medicine Residency

  • News & Events

  • About

Public Statement

This health center is a Health Center Program grantee under 42 USC 254b and a deemed Public Health Service employer under 42 USC 233 (g)-(n). No one will be denied access to services at GLFHC due to inability to pay; there is a discounted/sliding fee schedule available based on family size and income.

Accreditations

Copyright

Greater Lawrence Family Health Center

All Rights Reserved.

Website Design by Jackrabbit


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VIEW JOBS 1/17/2020 12:00:00 AM 2020-04-16T00:00 Established in 1980, the Greater Lawrence Family Health Center, Inc. (GLFHC) is a multi-site, mission-driven, non-profit organization employing over 600 staff whose primary focus is providing the highest quality patient care to a culturally diverse population throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program. GLFHC is currently seeking a Registered Nurse Care Manager to work with our Merrimack Valley Accountable Care Organization (MVACO) team. The RN, Care Manager provides care management and coordination for the MVACO enrollees and GLFHC patients across the care continuum, in close collaboration with members of the MVACO Care Teams, Primary Care Physicians, and Community Partners. Job Responsibilities: * Perform Comprehensive Assessments on all assigned patients identified as having Special Health Care Needs. * Supports patients through the coordination of care for designated high-risk patients at specific assigned site/s or for specific disease process/es. * Assess patient progress toward goals based on clinical judgment, review of patients self-monitoring tools, and trends in clinical data. * Provide face-to-face care management, including but not limited to: home visits, hospital visits, and office visits with PCP or specialist. * Ensures the development of patient centered care plans, and maintains constructive relationships between, care coordination staff with staff from all interfacing department staff. * Participate in ongoing quality improvement activities related to individual, team, and organizational performance improvement. * Utilizes ascribed processes for managing the needs of complex patients, initiating interventions based on physician approved patient-specific protocols and order sets (i.e. immunizations, consults age-appropriate preventive screening such as mammograms, colonoscopy, smoking cessation counseling). * Contributes to the documentation of individualized care plans for identified patients focusing on specific treatment goals. * Reviews, analysis and utilizes data and trends from relevant reports to determine if care coordination has improved patient status. * Participates in quality improvement activities, assisting in the design and implementation of multifaceted projects. * Engages in and facilitates other initiatives as assigned that may cross sites or disease process that align with the PCMH (Patient Centered Medical Home) model. * Sustains compliance with all professional and organizational requirements to meet position standards. * Regular and routine travel between clinic sites, patient homes, and to community facilities will be required with occasional travel in inclement weather. Requirements Experience * Minimum of two years nursing experience with 6 months acute care preferred. * Care Management Certification preferred. * Familiarity with computerized data management and research protocols. * Sound analytical and computer skills required. * Strong verbal and written skills required. * Spanish fluency preferred. Education * Graduate of an accredited professional nursing program with current Massachusetts Registered Nurse license * Bachelor's degree in nursing or related field required. GLFHC offers a setting that's flexible, rewarding and challenging. If you want to make an impact to the community we serve, apply today! Apply On-line Send This Job to a Friend * Programs & Services * For Patients * The Family Pharmacy * Locations * Family Medicine Residency * News & Events * About Public Statement This health center is a Health Center Program grantee under 42 USC 254b and a deemed Public Health Service employer under 42 USC 233 (g)-(n). No one will be denied access to services at GLFHC due to inability to pay; there is a discounted/sliding fee schedule available based on family size and income. Accreditations Copyright © Greater Lawrence Family Health Center All Rights Reserved. Website Design by Jackrabbit Greater Lawrence Family Health Center Lawrence MA

RN, Care Manager

Greater Lawrence Family Health Center