Complex Care Manager RN, Full Time

Boston Medical Center; United States; Hybrid; USD 90,000 - 130,000; Full time

Benefits offered by this job

HIPAA training

Job summary

Boston Medical Center seeks a Complex Care Manager RN to engage and coordinate care for high-risk patients across primary care, ED, and inpatient settings.

The role blends community outreach with clinic-based activities, including care planning and multidisciplinary collaboration, with a compensation structure described in the posted materials.

Qualifications

• Licensed to practice professional nursing as a Registered Nurse in Massachusetts.
• Two years of clinical experience preferred; care management experience desired.
• Driver’s license and reliable vehicle access required.

Responsibilities

• Identify and recruit patients for care management from lists and referrals.
• Develop patient-centered care plans focusing on chronic disease and social determinants.
• Collaborate with care team and community partners to implement the plan.
• Monitor goal completion and transition patients to inactive or graduated status as appropriate.
• Maintain HIPAA compliance and documentation standards.

Skills

Motivational interviewing

Interpersonal skills

Care management

Education

Nursing degree (Diploma, ASN or BSN)

BSN within 4 years

Master's in Nursing preferred

Job description

POSITION SUMMARY:

The Complex Care Manager works with relevant stakeholders to identify and engage patients in care management with a focus on patient experience, improving health and reducing cost. The individual is responsible for working with patients to identify strengths and barriers and to develop an individualized, patient-centered care plan. Excellent interpersonal skills, clinical expertise in conditions prevalent in the Medicaid population (Substance Use Disorder, Serious Mental Illness, Congestive Heart Failure [CHF], etc.), patient engagement skills and the ability to work independently and collaboratively are key requirements of the job. This position is a hybrid role requiring community and clinic presence as assigned, as well as an opportunity to work from home. Nurses in the position will work in 2 programs: Primary Care-based Complex Care Management and Transitions of Care. Nurses will collaborate closely with one another in the care of shared patients. Nurses will be designated to one of three clinical sites depending on the specific program he/she is a part of: Primary Care Practice, Emergency Department (ED), or Inpatient. Details on the 3 Care Management Programs are described below: Primary Care-based Complex Care Management: The CCM team will be embedded in local primary care practices. The team will partner closely with PCPs, Integrated Behavioral Health Professionals, Pharmacists, and other local resources in the Primary Care Practice to develop multi-disciplinary care plans. Nurses will proactively seek out opportunities to care for patients, including during PC visits, during ED or IP visits, out in the community, or on the phone. Nurses will be paired with Community Wellness Advocates who will partner with nurses on a shared patient panel, and will focus on social determinants of health. Transitions of Care (TOC): The Transitions of Care RN or SW provides comprehensive, wrap-around care for patients during their inpatient stay and immediately after their discharge. The RN/SW specifically works with patients who have the greatest risk of readmissions. By complementing existing care teams on the inpatient and outpatient side, the TOC RN/SW serves a critical role in connecting the dots across care providers and community agencies. The TOC RN/SW works at inpatient facilities, and aims to fully integrate with inpatient care operations – documenting in local medical records, participating in care planning efforts, etc. to ensure seamless care planning for patients while also serving as the link to continuing outpatient care. Clinical expertise in common high-risk medical conditions (e.g., CHF, diabetes, COPD, etc.), familiarity with home health and community-based resources, experience working at a safety-net facility or with the Medicaid population as well as excellent interpersonal skills, patient engagement skills and the ability to work independently and collaboratively are key requirements of the job. Compensation will be based on a salary/incentive plan. Position: Complex Care Manager RN Department: Pop Health Care Management Schedule: Full Time Location: North Shore Region

ESSENTIAL RESPONSIBILITIES / DUTIES:

• Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leaders
• Ability to execute core care management duties: Comprehensive assessment: bio-psycho-social-spiritual
• Collaboration with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning (HCP, MOLST)
• Implementation of care plan; Collaboration with community partners, such as VNA agencies, caregiver programs (PCA, ADH, AFC), DME providers and social service agencies
• Assessment of goal completion, with transition of patient to inactive or graduated status as appropriate
• Uses reflective, empathetic language and open-ended questions to understand what the patient truly wants for him/herself beyond being healthy and staying out of the hospital
• Meet the patient where he/she is; observe the patient without intervention or judgment
• Has knowledge of common chronic medical conditions presented in the population served and is able to: Educate the patient on their medication conditions and medications, and build their self-management skills
• Use motivational interviewing to promote behavioral change
• Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon
• Meets regularly with leaders at the local clinical site (Primary Care, ED, inpatient), and care management supervisor, to triage program issues appropriately
• Participates in local site operations, including team meetings, curbsides with care team members, etc.
• Actively participates in planning and growth of program with relevant stakeholders as needed, to respond to evolving needs of MassHealth ACO
• Facilitates interdisciplinary consultation on patient’s behalf through participation in rounds, team meetings and clinical reviews
• Complies with established metrics for performance and adheres to documentation and work flow standards
• Maintains HIPAA standards and confidentiality of protected health information
• Adheres to departmental/organizational policies and procedures
• Care Manager will work full-time at the clinical site of care
• Metrics: ED and inpatient visits; Total medical expense; Patient satisfaction; Clinical outcomes; Provider satisfaction; Avoidable admissions
• Other duties as assigned

JOB REQUIREMENTS

• Education: Nursing degree: Diploma, ASN or BSN (preferred), Ability to obtain BSN within 4 years BS or Master's in Nursing preferred
• Experience: A minimum of two years of clinical experience is preferred, with care management experience preferred. Experience working with vulnerable patient populations preferred. Home care or clinic preferred.
• Motivational interviewing preferred
• Clinical experience working with patients with multiple complex health issues preferred
• Care management preferred

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED

• Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts required
• Driver’s license and reliable access to a vehicle required

KNOWLEDGE AND SKILLS

This is a hybrid role that will require in-person presence in the community and clinical setting as assigned. There will be an opportunity to work from home as part of the work environment. Regular and reliable attendance is an essential function of the position.

NursingCM Compensation Range

NursingCM Compensation Range: $89,500.00- $130,000.00 This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensures as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), discretionary annual bonuses and merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family well-being. NOTE: This range is based on Boston-area data, and is subject to modification based on geographic location.

Equal Opportunity Employer/Disabled/Veterans

Boston Medical Center is an equal employment/affirmative action employer. We ensure equal employment opportunities for all, without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.

Boston Medical Center participates in the Electronic Employment Verification Program. As an E-Verify employer, prospective employees of BMC must complete a background check before beginning their employment at the hospital.

BMC requires all staff to be vaccinated against COVID-19 and flu, as well as receive a booster dose of the COVID-19 vaccine.