Summary of Position:

The Be Healthy Partnership (ACO) located in Springfield, MA is looking for a Nurse Care Manager (Full Time, Day Shift) to work within their existing practice as part of a team-based care delivery model.

The Nurse Care Manager provides quality patient centered care. Identifies patients who will benefit from coordination of care and initiates the care management processes in a quality focused, cost-effective manner across the continuum of care. The Nurse Care Manager uses a collaborative approach to providing quality patient care, while simultaneously working with physicians and clinical and administrative leadership to design and implement disease management protocols.

The Nurse Care Manager has a solid understanding of care management including disease management, preventive care and outreach work. They would create population based management strategies and processes that help patients manage their health care needs and foster high quality and cost-effective care throughout their Health Center.

The Nurse Care Manager would also supervise the daily activities of the Care Coordinator and the Community Health Worker to assure that job responsibilities are completed in a timely and efficient manner.

Essential Duties and Responsibilities:

• Coordination of Care
  • Focuses on the most complex Be Healthy patients and communicates and coordinates with all entities involved in the care of a patient to promote and maximize care coordination and patient satisfaction
  • Acts as a liaison between the health center, facilities and outside entities to resolve continuum of care issues related to patient care
  • Tracks urgent referrals and tests and document completion and appropriate follow up
  • Leads discussions with Physician advisors and MD’s about safe plan for transitions
  • Collaborates with community case managers and other health care advisors to ensure a smooth and safe continuum of care plan
  • Conducts relevant parts of patient Comprehensive Assessments and works with team to develop, implement, and track Care Plan
• Works with Nursing Team to manage the Chronic Disease and Preventative Health Registries and works to improve the outcomes of those diseases practice-wide. Utilizes the HEDIS work lists to reach out to patients who need a test or exam.
  • Identifies high-risk and/or non-compliant patients of targeted disease processes for intense care
  • Provides outreach to designated/targeted patient groups based on internal disease management database reports
• Promotes patient self-management of care
  • Educates patients and provides appropriate educational tools to promote self-management
  • Coordinates appropriate and necessary treatment or services required by that patient
  • Evaluates the effectiveness of the care plan and revises as necessary
  • Maintains clear, concise, objective and accurate documentation of goals and outcomes

Education and/or Work Experience Requirements:

• RN with Bachelor of Science Degree in Nursing preferred
• Minimally required: At least 2 years  of experience working in clinical setting
• Preferred: 5 years of experience working in outpatient nursing and/or care management experience
• Driver’s License and car required
• Strong communication and writing skills
• Excellent time management and organizational skills.
• Willingness to work some weekend/evening hours depending on project needs
• Demonstrated ability to work as an effective team member in a complex and fast-paced environment.
• Excellent interpersonal skills and demonstrated ability to interact professionally with culturally and educationally diverse staff and clients.
• Must have the ability to work with highly sensitive and confidential information
• Experience working with Senior Leadership across multiple settings preferred

Core Skills and Competencies:

• Ability to use a computer, Microsoft Office, EMR, and proficient in accessing and searching the internet

Physical Requirements:

·         Ability to safely and successfully perform the essential job functions consistent with the ADA, FMLA and other federal, state and local standards, including meeting qualitative and/or quantitative productivity standards.

·         Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards

·         Must be able to talk, listen and speak clearly on telephone

·         Must be able to use a computer workstation, viewing a CRT

About Be Healthy Partnership (ACO)

The Be Healthy Partnership is an alliance between Baystate, Baycare, Caring Health Center, and Health New England focusing on delivering high quality of care for the Medicaid population. The primary focus of this alliance is to improve the health and lives of our ACO members, as well as to control rising costs of care by implementing innovative delivery system changes that proactively meet the complex needs of our patients, including efforts to manage their behavioral and social needs in addition to their medical care.