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Care Manager, BPCI Population

Job ID 148191 Date posted 06/26/2018

Position Summary:
Lahey Health System participates in the Bundled Payment for Care Improvement (BPCI) ? Advanced Payment model that provides a single bundled payment to health care providers to furnish services efficiently, to better coordinate care, and to improve the quality of care.

The Care Manager, BPCI Population facilitates collaboration, communication and care coordination with all members of the healthcare team to support the patient across the bundle episode (acute hospital stay thru 90 days post-discharge). The Care Manager, BPCI Population is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained across the continuum of care for the identified BPCI patient population. The Care Manager, BPCI Population will assess, plan, implement and evaluate comprehensive, coordinated health services for the identified patient population to support their achievement of the highest level of self-management.

The Care Manager, BPCI Population responsibilities include working with physicians, patients, families, and the multidisciplinary team in the acute care, rehab, skilled nursing facility, homecare, community and physician practice setting to optimize quality and efficient outcomes; and decrease total medical expenses. The care manager assesses plans, implements, coordinates, monitors and evaluates options and services to meet the individual patient needs. The care manager works closely with the specialty/primary care providers and patient/caregiver to develop collaborative care plans to improve self-management and adherence to the provider?s treatment plan utilizing evidence-based best practice standards. The Care Manager builds relationships with the patient through use of motivational interviewing techniques to promote engagement in healthy behavior. The Care Manager, BPCI Population upholds the standards of professional case management practice and reports to the Supervisor of Care Management, LCPN.

Essential Duties & Responsibilities including but not limited to:
- The Care Manager for the BPCI population is accountable for providing safe patient care by demonstrating organizational skills that maintain and coordinate safe delivery of quality care for assigned patients/caregivers.
- Develops a culturally competent plan of care that identifies patient problems, expected outcomes, and addresses preventative measures.
- Evaluates effectiveness of care and adapts plan based on patient/caregiver response under the direction of provider.
- Serves as the liaison with patients, families to physicians, clinical staff, inclusive of inpatient case managers, and other departments involved with patient care, community and post-acute care providers.
- Advocates for patient and caregiver, responds to and facilitates resolution of patient questions and concerns.
- Conducts clinical assessments as appropriate for bundle patient populations that include medical, behavioral, functional, pharmacy and social needs of each patient. Shares this information with the healthcare team and with the patient/caregiver.
- Partners with patients and caregivers on self-management support for the duration of the episode, encouraging preventative health measures as well as post-acute recovery.
- Performs reassessment in patient progress toward goals and communicates with providers as appropriate throughout episode of care.
- Helps the patient to identify and overcome barriers.
- Provides or arranges needed patient education regarding specific health care skills and general disease management concepts.
- Identifies patients overdue for visits, in need of referrals, or admitted to emergency room, inpatient, sub-acute facilities or home health, and assists in arranging follow-up services as appropriate through the 90-day post-acute period.
- Identifies patients not meeting established goals and arranges for follow-up services by clinical pathway or as appropriate.
- Works independently to assess and evaluate the patient understanding of disease process, treatment plan lifestyle changes, and recognize changes in patient?s condition.
- Optimizes patient?s experience by communicating regularly with treating clinicians and other members of the health care team.
- Ensures appropriate post-acute documentation is available for reference in Lahey?s EMR for reference including assessment of outcomes, e.g., functional outcome assessments and discharge summaries from the all post-acute providers.
- Participates in quality improvement activities aimed to improve patient-population outcomes and associated processes.
- Works closely with the Supervisor of Care Management, LCPN, to support the Bundled Population.
- Collaborates with the Bundle Project Manager on strategies to achieve Bundle goals, such as quality and efficiency.
- Actively participates in Bundle team activities such as weekly/monthly Huddles, performance improvement team, etc., as requested.
- Communicates and coordinates with the healthcare team in the development of tools for optimal patient outcomes and reports findings.
- Interacts with care providers throughout the continuum of care to include acute hospital, skilled nursing facility, home health, and acute inpatient rehabilitation. The CM will be responsible for insuring the transitions of care are handled well and the needs of the patient are anticipated and met.
- Monitors and identifies problems of inappropriate utilization of resources
- Escalates patient concerns to Supervisor and Medical Director in a timely fashion to ensure quality care


Minimum Qualifications

Education: Bachelor?s degree in Nursing required. Master?s degree in health-related or business degree desirable.

Licensure, Certification & Registration: Active, unrestricted RN License in Massachusetts.
Active, certification in case management (CCM) required.

Experience: A minimum of 5 years medical/surgical or ambulatory clinic nursing required.

Skills, Knowledge & Abilities:
Experience working with BPCI population or Medicare ACO population highly desirable.
Demonstrates expert practice skills that include flexibility, priority setting, problem-solving, conflict resolution, negotiating and networking skills, decision making, work delegation and organization, and verbal / written communication skills.
Demonstrates effective teaching techniques applying adult learning principles.
Demonstrates ability to coordinate appropriate educational materials for patients and their support systems.
Demonstrates sound knowledge bases and actions in the decision making process for designated patient populations.
Answers and routes multiple phone calls and faxes, tasks and directs messages and information pertinent to care management.
Receives and arranges appointments for providers and patients for patient meetings, procedures, and appointments and sends correspondence as designated.
Adheres to all insurance, contractual & regulatory requirements as mandated.
Excellent interpersonal and organizational skills.
Interest in bundled payment and other alternative value-based payment models.
Experience with EPIC EMR highly desirable.
Basic skills in use of MS Office tools (Word, Excel, PowerPoint); familiarity with workflow tools and interest in data bases and metrics reporting tools.
Ability to function independently with minimal supervision.



About Lahey Health

The Lahey Model of Care - right care, right time, right place - is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.

Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.

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