Diabetes Nurse Case Manager

massgeneralbrigham; Somerville (MA); Hybrid; USD 90,000 - 110,000; Full time

Job summary

Mass General Brigham Health Plan Holding Company, Inc. is seeking a Diabetes Care Manager. The role bridges patients, providers, and community resources to reduce hospital and ED visits, improve medication adherence, and empower patients in diabetes management.

The position is full-time and hybrid, with on-site presence in Assembly Row, Somerville roughly once per quarter. An RN license in Massachusetts is required and BLS certification is necessary.

Qualifications

• RN licensure in Massachusetts (required)
• BLS certification required
• CDCES certification highly preferred
• 2-3 years of case management or discharge planning experience preferred
• Experience in chronic disease management, preferably diabetes

Responsibilities

• Assess members/patients' medical, behavioral, and social health.
• Define care goals and provide education and direction to patients and families.
• Develop and implement individualized diabetes management and care plans with providers.
• Modify care plans as patient needs change.
• Educate patients and families on medication and lifestyle adjustments.
• Conduct follow-ups via phone or telehealth; monitor adherence and A1c.
• Review complex cases with medical directors as needed.
• Maintain accurate reports and records.
• Collaborate with other health care professionals on the care team.
• Track progress using EHR and report outcomes to improve care strategies.

Skills

Patient education

Motivational interviewing

EMR documentation

Team collaboration

Microsoft Office

Education

Associate's Degree Nursing

Bachelor's Degree Nursing

Tools

Microsoft Office

Job description

Site: Mass General Brigham Health Plan Holding Company, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

Given equity, this position will pay somewhere between $90,000 to $110,000 annually.

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.

We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.

The Diabetes Care Manager will be the bridge between patients, healthcare providers, and community resources. The Diabetes Nurse Care Manager will reduce diabetes-related hospital and ED visits, improve medication adherence, and help patients gain confidence in managing their condition. You'll be a trusted advocate, educator, and problem-solver-making a measurable difference in the lives of those living with diabetes.

Essential Functions:

• Assesses members/patients' medical, behavioral, and social health
• Defines care goals of patients by providing education, information, and direction to each individual and family
• Develop and implement individualized diabetes management and care plans in collaboration with patients and their healthcare providers.
• Modify patient care plans as indicated by patients' responses and conditions.
• Educate patients and families on proper use of medication and lifestyle adjustments as needed.
• Conduct regular follow-ups-via phone, telehealth, monitor medication adherence, nutrition and physical activity, and A1c.
• Review cases with medical directors on challenging cases as needed
• Maintain accurate, detailed reports and records.
• Work with members who have had a recent hospitalization or ED visit to reduce the risk of readmission
• Collaborate with other health care professionals that are part of the member's health care team. You may work with multidisciplinary staff including; behavioral health care managers, dietitians, and social care managers, endocrinologists, and primary care providers.
• Track patient progress using electronic health records (EHR) and report on outcomes to improve care strategies.

Qualifications

Education

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

Licenses and Credentials

• Massachusetts Registered Nurse (RN) license required
• Basic Life Support (BLS) certification required
• CDCES Certification highly preferred

Experience

• At least 2-3 years of case management, utilization review, or discharge planning experience preferred
• Experience in chronic disease management, ideally diabetes, highly preferred
• Pediatric experience a plus

Knowledge, Skills, and Abilities

• Strong patient education and motivational interviewing skills.
• Familiarity with care plan creation and documentation in EMR.
• Ability to work collaboratively with diverse teams and populations.
• 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.

Additional Job Details (if applicable)

Working Conditions

• This is a hybrid role that requires an on-site presence at the office in Assembly Row, Somerville roughly once per quarter
• This is a full-time role with a M