Care Manager - HCA

Department Description: Healthcare Associates (HCA) is a robust adult primary care practice at Beth Israel Deaconess Medical Center offering comprehensive health services to enhance the quality of life for our patients. HCA services approximately 40,000 patients in over 200,000 patient visits per year.

Job Location: Boston, Massachusetts

Req ID: 45339BR


Job Summary: The primary responsibility is to provide practice-based care management and care coordination for patients with complex medical conditions in partnership with providers and other members of the healthcare team. The aim is to develop comprehensive proactive shared care plans and evaluate goals; increase engagement and activation, increase health literacy and understanding, address barriers to care, improve patients' health status, enhance coordination of care, and reduce potentially avoidable, or preventable medical admissions and unnecessary emergency services.

Essential Responsibilities:

1. Perform initial comprehensive clinical assessment of each patient including risk status, readiness to change and activation levels, self- management skills and needs of each patient.
2. Develop a shared care plan with patient/family, evaluating progress toward goals, modifying interventions as needed and document in EMR. Apply motivational interviewing techniques to support patient/family to achieve desired goals and promote self-management of chronic conditions.
3. Perform on-going assessments and monitoring including medications reconciliation, follow-up with patients during care transitions including a review of services, hospitalizations, recent ED visits or extended care admissions.
4. Educate patient/family on the importance of medication management and adherence, how to monitor symptoms and when to access health care services appropriately with an increase in symptoms.
5. Collaborate with PCP and communicate with patients various health care providers coordinating specialty referrals, transitions of care, ancillary services, and community services.
6. Implement plan of care and facilitate coordination of services through all transitions of care, including hospital, rehab, SNF, palliative care, and hospice. Coordinates and arranges community services as needed, such as home health, elder services, and SNF waiver.
7. Ongoing monitoring and follow up until the patient has met goals, demonstrates reduced risks and/ or no longer benefits or engaged with care management. Communicates with PCP as needed and coordinates plan with healthcare team when patient graduating from care management services.

Required Qualifications:

1. Graduate from an accredited Nursing Program required. Baccalaureate degree in Nursing strongly preferred.
2. License Registered Nurse required., and Certificate 1 Basic Life Support preferred.
3. 3-5 years related work experience required.
4. Behavioral strategies including motivational interviewing and relationship building with patients, staff and providers.
5. Ability to think creatively when developing plans of care for patients/families with complicated, complex needs.
6. Experience with computer systems required, including web based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint or Access.

Preferred Qualifications:

1. Homecare and/or care management and/or disease management experience. Knowledge of and experience with community resources.
2. Certified in care management or disease management.
3. Bilingual, Spanish

Competencies:

1. Decision Making: Ability to make decisions that are guided by general instructions and practices requiring some interpretation. May make recommendations for solving problems of moderate complexity and importance.
2. Problem Solving: Ability to address problems that are highly varied, complex and often non-recurring, requiring staff input, innovative, creative, and Lean diagnostic techniques to resolve issues.
3. Independence of Action: Ability to set goals and determines how to accomplish defined results with some guidelines. Manager/Director provides broad guidance and overall direction.
4. Written Communications: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.
5. Oral Communications: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.
6. Knowledge: Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations.
7. Team Work: Ability to work collaboratively in small teams to improve the operations of immediate work group by offering ideas, identifying issues, and respecting team members.
8. Customer Service: Ability to provide a high level of customer service and staff training to meet customer service standards and expectations for the assigned unit(s). Resolves service issues in the assigned unit(s) in a timely and respectful manner.

Age based Competencies:
Employees in this job must be competent to provide patient care to the following age groups: Young adult: 16-30 years, Middle Age: 30 - 60 years, Elderly: 60 -.
Physical Nature of the Job:
Light work: Exerting up to 20 pounds of force frequently to move objects. Some elements of the job are sedentary, but the employee will be required to stand for periods of time or move through out the hospital campus