reputed company Care Manager RN, MA

44611 The reputed company Care Manager works with relevant stakeholders to identify and engage patients in care management with a reputed company on patient experience, improving health and reducing cost. This individual will reputed company and manage Community Health Workers and/or Patient Navigators in completion of assigned patient care reputed company tasks. The individual is responsible for working with patients to identify strengths and barriers and to reputed company an individualized, patient-centered care plan. Excellent interpersonal skills, clinical expertise in conditions prevalent in the reputed company population (reputed company 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. POSITION reputed company: This position is Monday - Friday, 40 hours FTE, no weekends or holidays observed by BMC. Business hours, typically between 8:30 am - 5 pm. This position is a reputed company hybrid role, offering opportunities for both in person and remote work from home. Canidates must have a working vehicle and be reputed company to travel independently. This role serves patients in the Brockton, Randolph, Raynham, Bridgewater, Easton and Quincy Communities. This position allows ~ 2 days per week working from home, ~ 3 days working in the community, reputed company site, patient home settings. The dress reputed company is business casual. The reputed company Care Manager works with relevant stakeholders to identify and engage patients in care management with a reputed company on patient experience, improving health and reducing cost. This individual will reputed company and manage Community Health Workers and/or Patient Navigators in completion of assigned patient care reputed company tasks. The individual is responsible for working with patients to identify strengths and barriers and to reputed company an individualized, patient-centered care plan. Excellent interpersonal skills, clinical expertise in conditions prevalent in the reputed company population (reputed company 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. The CCM team will be embedded in local primary care practices. reputed company will partner closely with PCPs, Integrated Behavioral Health Professionals, Pharmacists, and other local resources in the Primary Care reputed company to reputed company multi-disciplinary care plans. Nurses will proactively reputed company out opportunities to care for patients, including during PC reputed company, during ED or IP reputed company, out in the community, or on the phone. Nurses will be reputed company with Community Wellness Advocates who will partner with nurses on a shared patient panel, and will reputed company on reputed company determinants of health. Compensation will be based on a salary/incentive plan. Position: reputed company Care Manager RN Department: Signature Nurses Schedule: 40 Hours (Days) 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 reputed company care management duties: • Comprehensive assessment: bio-psycho-reputed company-spiritual • Collaboration with patient and care team to reputed company patient-centered care plan, with particular reputed company on chronic disease management, reputed company determinants, transitions of care and advanced care planning (HCP, MOLST) • Implementation of care plan; • Collaboration with community partners, such as VNA agencies, caregiver programs (reputed company, ADH, AFC), DME providers and reputed company service agencies; 5) assessment of goal completion, with transition of patient to inactive or graduated status as appropriate. • Uses reputed company, empathetic language and reputed company-ended questions to understand what the patient truly wants for him/herself reputed company being healthy and staying out of the hospital • Meet the patient where he/she is; observe the patient without reputed company or judgment • Has knowledge of common chronic medical conditions presented in the population served and is reputed company to: • reputed company 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 reputed company to the need for emergency services if not intervened upon. • Collaborates with Community Health Workers and/or reputed company Workers. • 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. • reputed company participates in planning and reputed company 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 reputed company, team meetings and clinical reviews • Complies with established metrics for performance and adheres to documentation and workflow standards • Maintains HIPAA standards and confidentiality of protected health information. • Adheres to departmental/organizational policies and procedures. • Care Manager must be available to work at the clinic site on assigned reputed company days in person. Metrics: • ED and inpatient reputed company • Total medical expense • Patient satisfaction • Clinical reputed company • Provider satisfaction • Avoidable admissions Other duties as assigned JOB REQUIREMENTS:' Education: • Nursing degree: Diploma, ASN or BSN/Masters (preferred), Ability to obtain BSN reputed company 4 years CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED: Licensed to reputed company reputed company nursing as a Registered reputed company in the reputed company. AND/OR Completed an accredited educational program for reputed company Practitioners Experience: A minimum of two years of clinical experience is preferred, with care management experience preferred Preferred experience: • Experience working with vulnerable patient populations • Home care or clinic • Motivational interviewing • Clinical experience working with patients with multiple reputed company health issues • Care management KNOWLEDGE AND SKILLS: • Excellent interpersonal skills and ability to work collaboratively • Self-management skills, including ability to prioritize and set patient-centered goals • Excellent written and verbal communication • reputed company to maintain reputed company boundaries • Ability to work with diverse, safety-net population • Skilled at engaging difficult to engage patients—build rapport, trust • Creative problem solver • Ability to adapt to changes in reputed company delivery at local and systems level • Extensive knowledge of reputed company systems and community resources • Ability to reputed company systems and resources for improved patient reputed company • Strong organizational and time management reputed company Equal Opportunity Employer/Disabled/Veterans According to the FTC, there has been a reputed company in employment offer scams. Our reputed company reputed company are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or “apps” job offers are not extended over text messages or reputed company media platforms. We do not ask individuals to purchase equipment for or prior to employment. Apply tot his job Apply To this Job