Rn Case Manager-Icmp

The Integrated Care Management Program (iCMP) is a Primary Care practice-based care management/care coordination program.  It is an innovative program that focuses on improving the health of high-risk medically, psychiatrically, and/or psychosocially complex patients.  The objectives are to improve quality of care, patients, and provider satisfaction, and reduce overall costs.  This is accomplished through proactive patient outreach, engagement, and care coordination. This position requires an enthusiasm for helping patients achieve their health care goals while working in close collaboration with a multidisciplinary team of providers. This position is well suited for a nurse who understands the value of health equity in patient outcomes and who wants to contribute to the program's mission of supporting the care of medically complex patients.

This Case Manager position works in MGH Primary Care sites and collaborates to enhance the delivery of patient care services longitudinally and throughout the continuum of care.  The Care Manager meets patient's needs efficiently and expeditiously by continuously improving the patient's experience, helping to ensure the institutional standards of high-quality patient care, reducing cost, and improving patient and provider satisfaction.  Through broad knowledge of clinical care and systems management, the Case Manager evaluates, predicts, and facilitates the trajectory of patient care. The position requires a high degree of flexibility, independence, and willingness to participate in multiple activities and provide support to all members of the project team.

The iCMP Care Team members include Social Workers, Pharmacist, Community Resource Specialist and Community Health Workers.

Principal Duties and Responsibilities 

        Performs comprehensive nursing/psychosocial assessment for targeted patient population as defined by the Population Health Management (PHM) program.

        Centers the patient's health goals and assesses patient/family continuing care needs in collaboration with the interdisciplinary team to expedite and arrange non-acute care.

        Develops a comprehensive patient centered plan of care in conjunction with the patient, PCP, nephrology and specialty teams, family, and other members of the interdisciplinary team, appropriately utilizing the menu of services for patients, as well as insurance approved, community and practice-based services.

        Ensures the timely implementation of the plan of care and ensures that all elements have been communicated to the patient, family, and members of the interdisciplinary team.

        Facilitates access to the health care delivery system along the continuum by identifying key barriers in patient's self- management, assisting, and navigating these barriers and advocating on the patient's behalf when needed.

        Monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.

        Reviews appropriateness of hospital admissions. As appropriate, provide direct and ongoing care management to refer to PHM programs and community resources to avoid and reduce ER use and inpatient stays.

        Continuously evaluates and amends the plan to meet the patient's changing needs: coordinates, manages and documents all activities related to clinical approval processes and communicates relevant information to patients, families/interdisciplinary team members, payers, and vendors.

        Engages patients and families in ongoing Goals of Care conversations related to disease management/ progression. Refers to Palliative care as appropriate.

        Utilizing internal and external quality guidelines identifies, documents, and reports patient issues and system barriers; identifies potential solutions.

        Completely, accurately, and appropriately documents in the medical record.

        Complies with iCMP Standards of Practice and practice evidence-based care.

        Participates in iCMP/PHM meetings, case reviews, and the program's Quality, Equity and Safety initiatives.

        Collects data as designed by iCMP for ongoing analysis. 

PRINCIPAL DUTIES AND RESPONSIBILITIES:

PRINCIPAL DUTIES ND RESPONSIBILITIES: 

Qualifications 

• Registered Nurse, Bachelor's Degree Required
• Current Licensure in MA/NH, preferably both. Will compensate for 2nd licensure if needed.
• The optimal candidate has clinical background in an acute medical/surgical or primary care practice setting.
• Other relevant clinical experience may include (but is not required) post-acute care settings or care coordination/case management experience.

Skills/Abilities/Competencies

• Strong clinical assessment, problem solving and organizational skills.
• Strong interpersonal and communication skills, both written and oral.  
• Ability to work independently within a network of supports as needed.
• Goal oriented and accountable.
• Demonstrated ability to work in a complex setting.
• Ability to work in an interdisciplinary team-based environment and value the contributions of all team members.
• Promptly and courteously responds to patients, families, and internal/external customers.
• Promote a culture of safety and contribute to an equitable, just and diverse work environment where patients, families and providers thrive.