RN Care Manager — ACO Transitions of Care

Baystate Health; Springfield (MA); Hybrid; USD 90,000 - 122,000; Full time

Benefits offered by this job

Excellent compensation

Health, dental and vision insurance

Pet, home, auto and personal insurance

403b retirement with company match

Life insurance

Wellbeing reimbursement (gym, trainer,

Massage

Job summary

Baystate Health in Springfield, MA seeks an RN Care Manager for ACO Transitions of Care to coordinate care for a defined patient group. You will conduct whole-person assessments, develop individualized plans, and support patients with home visits or telephonic care to optimize outcomes.

Responsibilities include managing transitions from hospital or other facilities, reconciling medications, and documenting in patient records.

Qualifications

• Massachusetts RN License is required (and Driver’s License and BLS CPR)
• Minimum of 4 years of nursing experience
• 2 years of care management experience preferred
• Strong communication, interpersonal and problem-solving skills to advocate for optimal patient outcomes
• Capacity to work closely with patients, physicians and office staffs and managed care plans
• Strong organizational and prioritization skills
• Attention to detail and ability to work independently
• Excellent verbal and written communication and interpersonal skills; bilingual skills preferred

Responsibilities

• Coordinates, oversees, and directs the interdisciplinary team to provide patient-centered care.
• Identify patients for care management from physician referrals, transitions of care, health plans and complex lists from the ACO.
• Conduct whole person assessments and create individualized self-management plans.
• Advise patients to make informed decisions about their care as their advocate.
• Promote quality and cost-effective interventions in collaboration with PCPs and specialists.
• Manage transitions of care for hospital, behavioral health, ER or SNF discharges; review discharge summaries and arrange follow-up.
• Perform medication reconciliation and ensure understanding of discharge instructions.
• Provide disease or complex care management face-to-face or telephonically; conduct home visits when appropriate; titrate medications via protocols.
• Oversee Care Coordinators and Community Health Workers; address out-of-range quality indicators and help patients reach targets.
• Maintain current knowledge of care management resources and quality improvement methods; document in EHR/care management applications.
• Monitor program metrics such as ER utilization and hospital admission/readmission rates; collect data to identify utilization trends.

Skills

Care management

Interdisciplinary teamwork

Communication

Problem-solving

Advocacy

Organizational skills

Education

Associate Degree in Nursing

Bachelor of Science in Nursing

Job description

Baystate Health in Springfield, MA seeks an RN Care Manager for ACO Transitions of Care to coordinate care for a defined patient group. You will conduct whole-person assessments, develop individualized plans, and support patients with home visits or telephonic care to optimize outcomes.

Responsibilities include managing transitions from hospital or other facilities, reconciling medications, and documenting in patient records.