Case Manager

CareConnectMD, Inc.; Burlington, Northern (MA, KY); Hybrid; USD 75,000 - 90,000; Full time

Job summary

CareConnectMD, Inc. is seeking an on-site Case Manager in Massachusetts to support and coordinate care for patients in our ACO program. The role emphasizes utilization management, reducing hospitalizations, and improving transitions of care.

Strong communication and documentation are essential as you liaise with PCPs, families, facilities, and the care team. Applicants must reside in the Woburn, Wakefield, Burlington, or Lexington area and work onsite.

Qualifications

• At least 2 years of healthcare case management experience.
• Experience in long-term care setting is preferred.
• Knowledge of Medicare guidelines, SNF utilization, discharge planning.

Responsibilities

• Coordinate care across PCP, facilities, and care team.
• Monitor an assigned population of ACO patients with care management.
• Document timely and accurately in compliance with policies.
• Assist with transitions of care and reduce avoidable ER visits and hospitalizations.
• Engage families and facility teams to optimize outcomes.

Skills

Case management

Healthcare coordination

Communication

Documentation

Multitasking

Education

Licensed Nurse (LVN/RN)

Tools

EMR systems

Microsoft Office

CareConnectMD platform

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Case Manager

Full Time Professional

6 days ago Requisition ID: 1103

Salary Range: $75,000.00 To $90,000.00 Annually

Overview of Position

ACO Case Manager is responsible for supporting and coordinating the care of the patient participating in CareConnectMD's ACO program, with a strong focus on utilization management, reducing avoidable hospitalizations and ER visits, and improving transitions of care. The Case Manager serves as an extension of the patient's Primary Care Provider (PCP) and works closely with patients, families, nursing facilities, hospitals, providers, and the care team.

This role requires excellent communication, critical thinking, resourcefulness, and follow-through. The ACO Case Manager builds a strong relationship with patients, families, providers, and facility teams, serving as a reliable resource to help identify needs, resolve barriers, and coordinate appropriate care. Supporting the ACO's overall goals of improving quality and managing healthcare utilization.

This is an onsite position. Candidates must reside locally in the Woburn, Wakefield, Burlington, or Lexington, Massachusetts area and be able to work onsite.

Key Duties and Responsibilities

Patient & Care Management

• Manage and monitor an assigned population of ACO patients using CareConnectMD's patient-centered approach, recognizing each patient's individual needs, goals, preferences, and circumstances.
• Serve as an extension of the PCP, coordinating care, conduct regular outreach and communication among patients, families, facilities, and the care team.
• Develop innovative and creative approaches to patient care, identifying practical solutions to overcome barriers, improve engagement, and address complex patient needs.
• Maintains timely, complete, and accurate documentation in compliance with regulatory policies and procedures.
• Participates in multidisciplinary meetings, respecting and promoting patient choice and documents informed decision making.
• Collaborate with nursing facility staff to ensure that patient is receiving care that is appropriate and consistent with medical necessity.
• Collaborates and communicates with family members to optimize outcomes.
• Acts as an effective liaison to facilities (hospital, skilled nursing, assisted living, memory care, and mental health) to ensure continuity and congruity of services in accordance with the patient's Plan of Care.
• Specific to CareOne, build a strong close working relationship with Bridge care providers, CareOne facility operators and care team to ensure smooth.

Goals of Care & Advance Care Planning

• Ensures that patient's wishes are aligned and known to team. Participate in goals of care discussion.
• Verify that available code status and advance care planning documentation is complete and accessible to the care team, as appropriate.
• Support communication with patients, families, responsible parties, and providers regarding established goals of care.

Transitions of Care & Utilization Management

• Monitor patients when they are transferred to an acute setting (ED, hospital, LTAC), obtaining updates on patients for Clinical Team, facilitating transition of care and continuing to follow patient in the post-acute setting.
• Identify changes in condition, gather relevant information, and promptly escalation concerns to the appropriate clinician.
• Identify opportunities to support appropriate care in the most appropriate setting and reduce avoidable emergency department visits and hospitalizations.
• Assists facility for care coordination throughout the treatment episode at all levels of care as needed.
• Assist with provider-to-provider communication when needed.
• Communicates regularly with patient's primary care provider and other clinicians. Reviews and monitor patients' utilization of skilled Part A and Part B services in nursing facility to include documentation of medical necessity and continued stay review.
• Participate in root cause analysis of hospitalizations, ED visits, readmissions, or other utilization events when appropriate.

Care Coordination and Program Support

• Coordinates and communicates with the interdisciplinary team in the facility to effectively manage care plans and transition of care settings.
• Obtain and reconcile updated medication lists as part of care coordination activities.
• Support patient engagement and education regarding available ACO services.
• Facilitate telehealth visits, voluntary alignment form gathering, and other applicable ACO participation activities.
• Support completion of ACO quality measures, preventive care, and identified gaps in care.
• Coordinate with participating PCPs, provider groups, facilities, and ACO team members to support ACO initiatives.

Education and Experience

• At least 2 years of experience in healthcare case management.
• Experience in working in a long-term care setting preferred.
• Experience in working with frail, medically complex geriatric patients.
• Knowledge of Medicare guidelines, including skilled nursing facility utilization, medical necessity, discharge planning, and care coordination preferred.
• Experience working with electronic medical records, care management platforms and Microsoft office.

Essential Skills and Abilities

• Ability to solve practical problems and deal with a variety of concrete variables in situations.
• Works independently, set priorities and handle multiple tasks with a high level of efficiency.
• Creative, flexible, resourceful, and detail-oriented.
• Strong organizational skills with the ability to manage multiple patients, prioritize, and follow-up tasks.
• Ability to handle confidential and sensitive information.
• Excellent communication and interpersonal skills with the ability to effectively communicate with all levels of management, providers, patients, and family members, various healthcare settings including clinics, hospitals and/or skilled nursing facilities.
• Comfortable communicating with physicians and other clinicians regarding patient needs and changes in condition.
• Establishing and maintaining cooperative working relationships with others.
• Excellent composition, grammar, and business language skills.
• Work across different locations and time zones.

License/Certification

• Licensed Nurse (LVN/RN)
• Current/Valid state driver's license and insurance
• Must be a licensed driver with an automobile that is insured in accordance with state or organization requirements and is in good working order.

Core Competencies

• Drives results

To ensure the health and safety of our workforce while doing our part to protect those around us, CareConnectMD is requiring proof of full COVID vaccination for employees as a condition of employment, subject to legally recognized accommodations.