I. GENERAL SUMMARY

The Nurse Care Manager, utilizing the case management process, will work closely with the patient, the primary care physician, and the health care team to help ensure that patients receive comprehensive and coordinated care through the continuum. The Nurse Care Manager is an integral member of the Care Team, who conducts comprehensive clinical assessments, develops a patient-centric care plan, including goals of care and engages the patient through coaching, with the focus of preventing admissions, readmissions, and adverse events. The Nurse Care Manager assesses, plans, implements, coordinates, and evaluates the plan of care in partnership with the patient, family and other members of the health care team telephonically and through home visits. Identifying and tracking all co-morbidities and lab results through conversations with the physician, chart review, New England Quality Care Alliance (NEQCA) patient registry and the practice specific Electronic Health Records (EHR) platforms. Other duties will consist of providing input into program development, management, and reporting on enrollment aspects of the program.

Please note: this is a field based/remote position

II. KEY RESPONSIBILITIES:

  • Prepare for patient interaction by gathering information from reviewing the patient’s medical record when available and communicating with the PCP, and other clinical team members.
  • Coordinate all aspects of care for patients through the continuum.
  • Develop trusting, professional, caring relationships with patients and families, engaging respectfully and with utmost attention to service.
  • Must have the ability to work at Home in a HIPPA compliant environment
  • Assessments
    • During assessments with patients, the Nurse Care Manager will obtain information to identify and prioritize patient’s health conditions and establish goals that are patient specific and identified as part of the patient’s self-management goals.
    • Communicates abnormal findings and patient concerns in a timely and thorough manner to the provider.
    • During the assessment identify the patient’s knowledge gaps.
    • Conduct medication reconciliation and provide education and consult with NEQCA pharmacist, a member of the care team, as needed.
    • Work with the patient and caregivers to provide patient centered care which includes patient identification of specific health care goals.
    • Develop a care plan with the patient/family, providing all information to the PCP and set an appropriate timeline for achieving identified goals.
    • Provide telephonic calls to reinforce education, progress towards goals and reinforcement of the plan.
    • Utilize telemonitoring equipment to support wellness when indicated and as available.
    • Complete an in-home safety assessment and address specific safety risks (as required).
  • Documentation and ongoing patient support The Nurse Care Manager will complete documentation on visits and interventions per policies. In between face to face visits, the nurse will provide on-going support and education to each patient as identified within the care plan. Health management activities are provided by all members of the clinical team and may include, but are not limited to

    • During assessments with patients, the Nurse Care Manager will obtain information to identify and prioritize patient’s health conditions and establish goals that are patient specific and identified as part of the patient’s self-management goals.
    • Communicates abnormal findings and patient concerns in a timely and thorough manner to the provider.
    • During the assessment identify the patient’s knowledge gaps.
    • Conduct medication reconciliation and provide education and consult with NEQCA pharmacist, a member of the care team, as needed.
    • Work with the patient and caregivers to provide patient centered care which includes patient identification of specific health care goals.
    • Develop a care plan with the patient/family, providing all information to the PCP and set an appropriate timeline for achieving identified goals.
    • Provide telephonic calls to reinforce education, progress towards goals and reinforcement of the plan.
    • Utilize telemonitoring equipment to support wellness when indicated and as available.
    • Complete an in-home safety assessment and address specific safety risks (as required).
  • Quality Initiatives In addition to patient-specific activities, the Nurse Care Manager will undertake quality improvement activities to improve the clinical program of NEQCA.

    • Educate physicians, office staff and patients on the patient centered medical home model as needed.
    • Collaborate around all aspects of the program as requested by identified managers, Work with the team, which will include the Local Care Organizations staff, NEQCA Director of Care Management and Medical Director to develop plans and manage implementation of the plan.
    • Coordinate development efforts with all members of the team.
    • Identify problematic design issues and communicate those issues with your manager to identify options to reduce potential barriers. Share best practices with the entire clinical team to insure a cohesive program.
  • Monitor practice transformation operations

    • Work with the physicians and office staff to implement agreed upon intervention strategies.
    • Attend regular team meetings to provide updates on program status and to identify challenges and opportunities for projects to be successful.
    • Attend all trainings provided by NEQCA.
    • Work with the team to identify and overcome barriers to implementing improvement ideas; coordinate implementation of agreed upon modifications as necessary, and conduct ongoing analysis of improvement efforts.
  • Maintain collaborative, team relationships with peers and colleagues in order to effectively contribute to the working group’s achievement of goals, and to help foster a positive work environment, including working collaboratively with NEQCA staff, and all affiliated organizations.

  • Has an understanding of management of chronic health conditions and population management.

  • Facilitate patient empowerment and self management by promoting educated, independent patient choices.

  • Support NEQCA Quality Initiatives.

  • Perform other similar and related duties as required or directed.

III. JOB REQUIREMENTS

JOB KNOWLEDGE AND SKILLS:
  • Experienced in acute, subacute, or home care, palliative care and hospice experience a plus
  • Organizational skills required for calendar management and meeting timelines defined within the program
  • Familiarity with Motivational Interviewing a plus
  • Excellent communication and interpersonal skills
  • Ability to prioritize and resolve critical issues efficiently and effectively
  • Ability to work with all levels of the organization
  • Ability to effectively present ideas and information
  • Proficiency in Windows platform, including Word, Excel, PowerPoint.
  • Demonstrates, after receipt of training, use of all applicable electronic systems/applications including but not limited patient registry, EHR, population management systems
  • A robust understanding of management of chronic health conditions and population management
EDUCATION AND EXPERIENCE:
  • Registered nurse with an active professional Massachusetts license, BSN desired
  • 3-5 years of clinical experience in an acute care/home care or skilled nursing facility.
  • Certification as a Case Manager and experience in case management strongly desired
LICENSES

Registered Nurse in Massachusetts

V. WORKING CONDITIONS/PHYSICAL DEMANDS:

  • Work is in a fast paced office-based setting.
  • Reliable transportation is necessary. The NEQCA office is located in Braintree with travel to Local Care Organizations and community hospitals intermittently.
  • Work sometime includes meetings outside of normal business hours