Job ID R1676 Full / Part Time:Full time
The Outpatient Nurse Care Manager is responsible for managing the complex patients (top 5%) 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. 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 physicians and other health team members along the patients 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.
- Responsible for coordinating and providing care that is safe, timely, effective, efficient, equitable, and client-centered to the patients in the risk contracts.
- Responsible for appropriately identifying patients for care management utilizing multiple sources including physician 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.
- Manages transitions of care for patients discharged from the hospital, emergency room, or from a skilled nursing facility. Responsible to review 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.
- 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.
Required Work Experience:
- Registered Nurse in the State of Massachusetts.
- 5 years clinical nursing experience required
- Valid Drivers License
- Bachelor's Degree preferred.
- Outpatient nursing and / or care management experience strongly preferred
- Experience with educating patients and patient goal setting is essential as is problem solving skills to advocate for optimal patient outcomes Qualified candidates must have excellent written and verbal communication and interpersonal skills and ability to work independently
- Hours- Full Time 40 hours Monday - Friday.
- Locations- Baystate Primary Care practices - Southwick and Feeding Hills, MA
- Resume required
Associates of Science: Nursing (Required), Bachelor of Science: Nursing
Basic Life Support - American Heart Association, Driver License - Various, Registered Nurse - State of Massachusetts
Baystate Health 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.
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