Nurse Care Manager

Department Description: OBGYN

Job Location: Boston, Massachusetts

Req ID: 45669BR


Job Summary: The BIDMC Nursing Mission is to build on a legacy of nursing excellence by caring with compassion, advancing the art & science of nursing, and advocating for the health of patients, families, and communities. The primary responsibilities of the Nurse Care Manager are to provide care management support to patients with complex medical conditions. The Nurse Care Manager will also play an integral role as a core member of the Care team in developing programs within the division and BIDMC. The aim is to develop comprehensive proactive shared care plans and evaluate goals; increase health engagement and activation, increase health literacy and understanding, address barriers to care, improve health status, enhance coordination of care, and reduce potentially avoidable or preventable medical admissions and unnecessary emergency services. Training, evaluation and competencies for this role are overseen by a Nurse Leader to the department.

Department Specific Job Responsibilities:

1. Provide obstetrical assessment and case management of high-risk obstetrical patients with a concentration on support, education and care coordination.
2. Work directly with clinical leadership to develop system-based programs addressed at decreasing negative impacts on pregnancy and improving perinatal outcomes and maternal health.
3. Obstetrical Nurse Care Manager is responsible for education of patient's health, monitoring and assessing maternal risk factors and coordinating treatment plans with care team.
4. Provide telephone assessments and teaching to patients as well as direct clinical care and support throughout pregnancy. Nurse care manager will have skill set to engage and empower patients to participate in care plan.
5. Develop system for transition to primary care postpartum that includes care coordination and hand off to PCP.

Essential Responsibilities:

1. Perform initial comprehensive clinical assessment of each patient including risks status, readiness to change and activation levels, self -management skills and needs of each patient.
2. Track and monitor patients under caseload through all transitions of care and enter all patients into a registry. Perform ongoing assessments and monitoring including medical reconciliations, follow-up with patients during transitions, hospitalizations.
3. Communicate and collaborate with other health care team providers including PCP, specialists, visiting nurses, hospital case managers, skilled nursing facilities, rehabilitation facilities, discharge planners, social workers, community resource specialists, outpatient medical providers.
4. Work with care team providers to consult on services and treatment plans.
5. Collaborate with other BIDMC outpatient departments to create hospital wide continuity of care for specified complex medical condition.
6. 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.

Required Qualifications:

1. Graduate from an accredited Nursing Program required. Master's degree in Nursing or licensed Nurse Practitioner strongly preferred.
2. License Registered Nurse required., and Certificate 1 Basic Life Support required.
3. 3-5 years related work experience required.
4. 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. Experience working with Substance Abuse and Addiction population and specifically Suboxone induction and maintenance.
2. Care Management experience.
3. Knowledge and experience with community resources for substance abuse population. Ability to create community based plans of care for patients and families utilizing these resources.

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