Open position

Job Type: Regular

Time Type: Full time

Work Shift: Day (United States of America)

FLSA Status: Exempt

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

osition Summary:

BILHPN has oversight of population health and is responsible to ensure that quality, efficient care management services are provided to the BILHPN provider’s risk populations. The Care Manager provides care management services to the BILHPN primary care physicians focusing on at risk, high cost, and chronic/complex condition patient populations. Collaborates with the primary care team to develop strategies for their at risk patient population through care coordination, condition management education and community resource support. Responsibilities include working with physicians, patients, families, and the multidisciplinary team in all settings to optimize quality, reduce readmissions and decrease total medical expenses. The Care Manager assesses, plans, implements, coordinates, monitors and evaluates options and services to meet the individual patient needs. This role works closely with the skilled nursing facility team, the primary care provider and patient to develop collaborative care plans to improve self-management of chronic conditions utilizing evidence-based best practice standards. The Care Manager is accountable for ensuring efficient and professional services for patients and families that are designed to promote and enhance their physical and psychological functioning with attention to the social and emotional impact of illness and disability. The Care Manager upholds the current standards of professional case management practice, and reports to the Post-Acute Program Director.

Job Description:

Essential Duties & Responsibilities including but not limited to:

The Care Manager supports the primary/specialty care physicians in population health management by focusing care coordination attention on the at-risk population driving utilization and costs to improve efficiency, quality and patient satisfaction. Engages physician and practice team in proactive patient management by addressing medical /psychosocial/functional health care needs, follow-up, and referrals. Utilizes a designated patient roster report to review at risk population with providers and the Post-Acute Program Director to prioritize program enrollment, care planning, addressing prognosis and potential palliative/hospice care referrals. Offers and coordinates free care consultation to patient/caregiver telephonically, to reinforce appropriate follow up care, condition management, provide education and community resource navigation. Aims to improve the individual’s overall quality of life by supporting treatment goals, empowering them to be advocates for themselves and assisting them to obtain benefits, access to health care and connect to social and community services. Advocates for patient and families, responds to and facilitates resolution of patient questions and concerns. Seizes opportunities to reduce gaps in care by making recommendations for efficiency, quality and cost improvement. Understands organizational goals and accountability towards maximizing organization performance. Works collaboratively with other professionals to maintain a team-oriented approach to care management and incorporates shared decision making in all patient interactions.

Communication: The Care Manager interfaces at prescribed intervals with patients, families, the health care team, community agencies, vendors, and health system staff to ensure efficient, quality care delivery. Reviews at risk cases with the Post-Acute Program Director and Medical Director as needed, in a concise, effective, professional manner. Addresses medical /psychosocial concerns and makes recommendations to improve efficiency and quality care. Serves as an educational/informational resource to the provider care team, and patient/family regarding inpatient/outpatient resources. Participates in care team huddles by communicating important information on at risk cases with interdisciplinary team. Documents in the case management record clear, concise, timely notes that addresses patient problems, barriers, goals, support systems, advance directives, transition plan and case management interventions to improve efficiency, quality and reduce cost. Patient and Provider Satisfaction: The Care Manager strives to provide a quality patient and provider experience while working in collaboration with the patient/family and members of the healthcare team. Coordinates care to maximize the value of services delivered to patients to improve health care outcomes. Incorporates shared decision making in all aspects of patient care interactions. Promotes patient autonomy and self-management at every encounter. Creates a culturally sensitive care plan while utilizing health literacy and language appropriate patient education materials to promote engagement in plan. Quality Improvement: The care manager is responsible for timely reporting of quality events in the inpatient/outpatient care setting to ensure continuous monitoring for quality improvement. Refers quality/risk management cases to the Post-Acute Program Director or Medical Director and reports events per BILHPN policies, regulatory and /or health plan requirements. Identifies opportunities to improve patient adherence with ACO quality measures. Reports and follows up on patient complaints to ensure quality care and patient satisfaction. Participates in quality improvement projects and other educational sessions offered by the employer to promote continuous learning.

Organizational Requirements:

Maintain strict adherence to the Lahey Health Confidentiality policy. Incorporate Lahey Health Standards of Behavior and Guiding Principles into daily activities. Comply with all Lahey Health Policies. Comply with behavioral expectations of the department and BILHPN. Maintain courteous and effective interactions with colleagues and patients. Demonstrate an understanding of the job description, performance expectations, and competency assessment. Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards. Participate in departmental and/or interdepartmental quality improvement activities. Participate in and successfully completes Mandatory Education. Perform all other duties as needed or directed to meet the needs of the department.

Minimum Qualifications:

Education: Graduation from a practical nursing program or nursing program.

Licensure, Certification & Registration: Minimum License required: Active, unrestricted Massachusetts or New Hampshire LPN or RN license. Certification in Case Management (CCM) preferred.

Experience: 1. Case management and nursing experience preferred. 2. Experience working in Skilled Nursing Facilities with in depth knowledge of Medicare Guidelines preferred 3. Experience with Medicare population in managed care preferred Must be proficient in computer skills, internet, information technology and electronic medical record use.

Skills, Knowledge & Abilities: 1. Strong development, analytic and systems building skills. 2. Must be facile with physician relations, developing systems and procedures, developing and operating a capitated managed care infrastructure, continuous quality improvement, human resources management and fiscal management. 3. Excellent written and verbal communication skills. Must have a professional demeanor and the ability to deal with physicians, senior management, and local industry. 4. Capable of serving as a spokesperson and leader of the integration process and communicate the vision to others in the community. 5. A well-defined style that demonstrates confidence, maturity, self-motivation, high energy, collaboration, high intellect and leadership qualities. 6. Excellent interpersonal skills, be an appropriate risk taker, politically savvy, diplomatic, able to deal with ambiguity, flexible, organized, results oriented, a hard worker, a quick study, good with details and have integrity. Ability to function as a facilitator who can further the organization to serve the evolving Network.

Key Relationships:

1 Post-Acute Program Director Direct Reporting Relationship

2 BILHPN Post-Acute Medical Director Consultative

3 Care Team Members Collaborative

4 BILHPN Providers Collaborative

Scope/Impact Statement:

Work Schedule: Indicate either Yes or No as appropriate. Hours of work may be subject to change based upon the needs of the business/department.

On Call: No Shift Rotation: No Weekends: No

Physical Requirements & Environment: Required

For each category, select ONE option from choices below by placing an X in the space to the left of the entry.

Mental and Visual Attention Required

a) The position requires basic mental and visual attention much or all of the time

b) The position requires periods of concentrated mental and visual attention.

c) X The position requires a high degree of mental and visual concentration.

Physical Exertion

Weight

d) X Nature of work requires lifting or moving light weight (up to 20 pounds).

e) Nature of work requires lifting or moving medium weight (over 20 and up to 75 pounds).

f) Nature of work requires lifting or moving heavy weight (over 75 pounds).

Dexterity

g) X Flow of work and character of duties require average manual coordination.

h) Flow of work and character of duties require above average manual coordination.

i) Flow of work and character of duties require high manual coordination.

Range of Motion

j) X Duties require average range of motion.

k) Duties require above average range of motion.

l) Duties require high range of motion.

Physical Conditions

m) X Performance of duties allows for variation in positioning and tasks.

n) Performance of duties requires remaining in position for prolonged periods of time.

Repetitive Motion

o) X Assignments require occasional repetitive motion.

p) Assignments require frequent repetitive motion.

q) Assignments require constant repetitive motion.

Working Conditions

r) X Working conditions include minimal exposure to elements such as odor, noise, dust, chemicals, temperature extremes or airborne pathogens.

s) Working conditions include occasional exposure to elements such as odor, noise, dust, chemicals, temperature extremes or airborne pathogens.

t) Working conditions include continuous exposure to elements such as odor, noise, dust, chemicals, temperature extremes or airborne pathogens.

Exposure to Hazardous Materials

u) X Performance of duties generally does not involve exposure to hazardous materials.

v) Performance of duties occasionally involves exposure to hazardous materials.

w) Performance of duties frequently involves exposure to hazardous materials.

Patient Care Conditions (select ALL that are applicable)

x) Position entails exposure to blood and body fluids, standard precautions must be used.

y) Assignments include transporting, transfer and positioning of patients.

z) Incumbent must be continuously prepared to prevent a patient fall.

Sensory Requirements (select ALL that are applicable)

aa) Performance of duties requires the ability to discern and identify colors

bb) Performance of duties requires the ability to discern sharp from dull and hot from cold

cc) Performance of duties requires the ability to hear soft and loud noises

Patient Care/Patient Contact Designation (check only one of the items listed below)

X Position has a direct impact upon health outcomes of the patient.

_ Position facilitates the process that may impact patient access to services.

_ No patient care/contact, and does not facilitate the patient care process or directly impact health outcomes.

This Job Description is intended to describe the general nature and level of work being performed by people assigned to this classification. It is not intended to be construed as an exhaustive list of all responsibilities, requirements, duties and skills required of personnel so classified. Additional duties and responsibilities that are specific to the Department or Unit are identified and maintained by the Manager as an Addendum to the Job Description.

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment. Learn more about this requirement.

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Equal Opportunity Employer/Veterans/Disabled