Emerging Risk Care Manager, RN

The Emerging Risk RN Care Manager is a key clinical member of the Emerging Risk Program a component of the CARE Compass Program. This role is responsible for providing high-quality, patient-centered care management for individuals identified as "rising risk" based on medical conditions, SDOH needs and an inflection in utilization patterns. Operating at the top of license, the RN Care Manager focuses on clinical assessment and design of time limited goals promoting positive patient outcomes. She/he engages with the patient/family in proactive care planning, symptom identification and reinforcement of treatment plans, with patient education to support engagement with primary care and successful linkage to community resources. These efforts align with the Care Compass mission of enhancing stability at home, improved outcomes and reduction in ED and hospital utilization. Working within a defined interdisciplinary team including Community Health Workers, and Patient Navigators, the RN CM will support identification of patients with medical conditions and gaps in care which may contribute to either an uptick or anticipated uptick in utilization. Understanding that SDOH strongly influences disease management, the RN Care Manager will need to work closely with a non-clinical bachelor's-level Community Health Workers and Patient Navigator (CCC) Care Coordinator to provide administrative and logistical support. Together, this multidisciplinary team will offer time limited goal directed patient centered care coordination. The team will have access to behavioral health expertise and may refer to a pharmacist who specializes in medication management, MTM, and can provide medication reconciliation. This team-based model allows the RN to focus on patients with new or chronic medical conditions ensuring the highest level of efficiency and effectiveness. The RN Care Manager is also responsible for ensuring compliance with complex care documentation requirements, payor contract care management requirements and may support quality measures to improve patient outcomes. The RN Care Manager is flexible and can adapt to an ever-changing health care environment. This role requires willingness to assess, participate in ongoing process improvement activities and innovate processes and workflows to support time limited targeted care coordination. This role will utilize a variety of intervention modes including but not limited to video, telephone and patient gateway (MGB Patient Portal).

Qualifications:

• Associate's Degree Nursing required. Bachelor's Science Nursing preferred.

• RN license required.

• 2+ years case management, utilization review and/or discharge planning experience preferred.

• Experience with health coaching preferred.

• Experience with SDOH and/or BH preferred.

Additional Knowledge, Skills and Abilities:

- Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
- Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
- Ability to establish strong rapport and relationships with patients and staff.
- Proficient in Microsoft Office and industry related software programs.
- Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
- Ability to maintain client and staff confidentiality.
- Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
- Knowledge of Healthcare and Managed Care preferred.

Schedule and Work Model:

• Full time, Monday through Friday, approximately 8am-4:30pm ET.

• Primarily remote / work from home with occasional travel to Assembly Row in Somerville, MA required.

• On remote workdays, employees must use a stable, secure, and compliant workstation in a quiet environment. Teams Video is required and must be accessed using MGB-provided equipment.

Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.