Massachusetts Veterans Jobs

POSITION SUMMARY: Signature Medical Group is a NCQA recognized Patient Centered Medical Home (PCMH) organization. The model promotes primary care that is accessible, continuous, comprehensive, family‐centered, coordinated, compassionate, and culturally effective. The Care Manager position is an integral member of the PCMH team and focuses on the following goals for identified high risk patient populations:

• Managing care via integrated care plans, health goals and continuous assessments • Providing self care resources along with activation interventions and teaching • Coordinating care by optimizing the EMR, leveraging community resources and improving intra and inter team communications • Working as part of a multidisciplinary care team to provide patient-centered care and to lower total medical expense of high risk/high cost patients • Providing Transitional Care Management (TCM) services for eligible patients as they transition back to the community setting after a stay at certain facility types.

The goal is optimizing the patient’s health status while lowering total medical expense, which will be measured via specific quality outcomes.

The Care Manager will work in the primary care setting in close collaboration with the patient’s primary care team which includes the MD/NP, social worker, nurse, secretary, medical assistant, and other key stakeholders/staff as needed. The meaningful involvement of the patient and patient’s family/support system is integral to the success of this model.

In a fast-paced and multicultural setting, the Care Manager works to improve the health outcomes of at risk patients. The Clinical Care Manager works as part of a multidisciplinary care team to integrate evidence based clinical guidelines in the development of patient centered care plans.

Initiate TCM Visits: Transitional Care Management CM will function as an intermediary between the medical teams and patients. TCM is intended to reduce potentially preventable readmissions and medical errors during the first 7-14 days following discharge from the acute setting. Acute awareness is needed to prevent unnecessary readmissions, improve HCAHPS, drive positive discharge outcomes and reduce LOS, and review ER utilization using proactive approaches to any barriers.

The Care Manager provides targeted clinical/non-clinical interventions with the goal of avoiding hospitalization, emergency room visits and out of network specialty care, while improving health outcomes and lowering total medical expense. This individual helps to coordinate care across multiple clinical and non clinical settings and helps patient/families understand their health care options.

KEY RESPONSIBILITIES:

1. Identifies the targeted at risk population based on predictive modeling, bio-psychosocial factors, social factors, cost/ utilization factors or other risk stratification strategies including repeated social/health crisis admissions etc. Actively reviews reports, considers case management impact, recommends and makes modifications to the plan of care as needed. 2. Conducts analysis based on predictive modeling and performs chart review in order to identify gaps in care or services. Conducts outreach to facilitate follow up care. 3. Promotes effective and efficient utilization of clinical services. Utilizes available reports to proactively prioritize the needs of high risk patients and coordinate interventions. 4. Communicates with at risk patients and assesses the health, educational, and psychosocial needs of the patient/family. Implements use of standardized assessment tools such as depression screening, functionality, health risk, medication adherence, dependence/ addiction, risk for falls. 5. Provides self-management resources to empower the patient/family to build self-care capacity. 6. Takes the lead to ensure continuity of care extends beyond the clinical setting. Serves as liaison to acute care hospitals, specialists, and post-acute care services. Facilitates interdisciplinary care team meetings to identify at risk patients, identify treatment goals for enrolled patients, and to ensure continuity of care. 7. Participates in quality improvement activities related to the management of patient care. 8. Follows standards of work for care management (i.e. documentation) and consistently maintains appropriate caseloads. Participates in the refinement of and development of new standards of work. 9. Meets regularly with the Manager of Care Coordination (or other designee) to review caseload and discuss barriers/challenges and review performance compared to current targets/expectations. 10. Communicates regularly with patient/family during acute care transitions. Performs medication reconciliation, ensures PCP or specialist follow-up, performs symptom assessment, and provides relevant education (i.e. review of discharge instructions). 11. Remains current with care management skills related to effective communication, patient self management, motivational interviewing, and behavior change strategies. 12. Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment. a. Commits to recognize and respect cultural diversity for all customers (internal and external). b. Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.

2. Participates in daily huddles and escalates issues that can lead to process improvement.

3. Performs other duties as assigned.

   REQUIRED KNOWLEDGE & SKILLS:

   • Demonstrates patient focused interpersonal and communication skills to interact in an effective manner with practitioners, the multi stakeholder health care team, community partners, patients/ families with diverse backgrounds, values, and religious and cultural ideals. • Strong assessment and triage skills • Knowledge of chronic conditions, and evidence based guidelines, prevention and wellness strategies and patient activation and education strategies. Demonstrated ability to use behavioral strategies such as motivational interviewing. • Knowledge of patient centered medical home model, population management concepts, EMRs strongly preferred. • Demonstrated critical thinking skills and ability to analyze complex data sets. Ability to triage and manage complex clinical issues utilizing assessment skills and protocols. • Demonstrated competency in computer applications particularly Excel. • Ability to affect change, works as a productive and effective team member, and adapt to changing needs/priorities. • Ability to prioritize, multitask, and work in rapidly changing environment with multiple demands. • Demonstrated positive relationship building skills and ability to collaborate with other disciplines both in and out of network. • Ability to work autonomously and be accountable for clinical performance measures. • Ability to travel to select practice sites, as needed. • Demonstrated problem solving, critical thinking, and analytical skills.

   EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER: I. Education: Graduate of an NLN-accredited School of Nursing; LPN or Bachelors’ of Science in nursing or higher in clinical field preferred. II. Experience • Bilingual/Bicultural preferred (Spanish, Haitian Creole, Portuguese) • Minimum of 3 years of broad clinical experience across a variety of settings including ambulatory and/or community health nursing care management/case management/ chronic disease management preferred. • Experience with substance abuse and behavioral health conditions preferred. • Completion of self-management support training preferred. • Experience in data analysis and/or chart review preferred. III. Certification/Licensure: Current LPN or RN license in the Commonwealth of Massachusetts. Case Management certification preferred. Valid driver’s License IV. Software/Hardware: Experience with electronic medical records preferred, proficiency with Microsoft Office products with special attention to Excel, experience with predictive modeling applications preferred

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