- Medford (137 Main Street) - Internal Medicine
- Westwood (90 Brigham Way) - Primary Care
- Handles all transitions of care for MGB CP patients from inpatient to outpatient/home as applicable.
- Conducts engagement, outreach and education activities for patients identified as requiring care coordination services.
- Routinely collaborates with the patient's PCP (Primary Care Physician), specialist physicians as well as other members of the care team regarding high priority patients and the patient centered plans of care.
- Initiates telephonic contact with eligible patients to conduct an initial assessment, patient/family health education, and develop a patient centered plan of care.
- Serves as a key resource to assigned patients, helping to proactively address their questions, concerns, and care needs by guiding and facilitating access to providers and services.
- Communicates with other health care practitioners throughout the continuum regarding patient's care needs, utilization plan and applicable follow up plans.
- Establishes a consistent schedule of communication and reporting with involved providers and the patient with intended goal of reviewing patient status and progress toward goals.
- Collaborates with and seeks feedback from the program primary care physician, care coordination management and/or medical director regarding challenging patient situations.
- Conducts case reviews at practice and /or care management meetings.
- Commitment to coaching (rather than instructing) patients to improve their health behavior to attain their health- related goals.
- Active RN license to practice in Massachusetts required, BSN preferred.
- Minimum of 5 years of experience in a hospital, health plan or community practice case management role required.
- Certification in case management (CCM) or other applicable professional certification preferred.
- Previous experience working in an ambulatory setting such as a health center or physician's office is preferred.
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rn, care management - Medford, MA , USA, United States - Partners Healthcare System
Description
About Us
Mass General Brigham Community Physicians (formerly known as Partners Community Physicians Organization) is a member of the Mass General Brigham system, founded by Brigham and Women's Hospital and Massachusetts General Hospital.
Our continued dedication to clinical excellence, focus on diversity, equity, and inclusion, and generous employee offerings, such as our competitive benefits package, allow our professionals to build an exciting career as we all work together to positively impact the health of our patients.
The Opportunity
We are currently hiring a full-time, 40-hour RN Care Manager to support iCMP (Integrated Care Management) at two of our practices:
As a hybrid opportunity, the position entails onsite coverage 2 days per week on site (days can be flexible dependent on candidate's schedule) and remote coverage 3 day per week.
The iCMP RN Care Manager is responsible for establishing, implementing, monitoring, and evaluating high-quality, cost-effective care plans for a designated group of patients in the ambulatory setting.
The individual will need sound clinical judgment, effective problem-solving skills, critical thinking, excellent organizational and interpersonal skills, experience with team-based care, and the ability to multitask.
A broad-based knowledge of available health services across the continuum, insurance benefit design and reimbursement methods, and experience in acute or community case management will be needed to be successful.
Responsibilities
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