RN Care Manager, MassHealth ACO

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Location: Burlington, MA
Job ID: 148266-1A
Date Posted: Nov 27, 2019
Category: Nursing

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Job Description




Position Summary:

LMH-ACO is responsible for improving coordination of patient care, reducing unnecessary hospitalizations and readmissions, emergency department visits and revisits, and reducing total cost of care over time. LMH-ACO will provide services in collaboration with contracted Managed Care Organizations as well as Community Partners for Behavioral Health and Long Term Services and Supports (LTSS), as appropriate.

The Care Manager provides care management support to the LMH-ACO primary care physicians focusing on the high and moderate risk, high cost, chronic condition patient population. The Care Manager collaborates with the primary care physician, LMH-ACO care team, and community partners for behavioral health and long term services as appropriate to develop care plans on the high and moderate risk patient population. Responsibilities include working with physicians, patients, families, and the interdisciplinary LMH-ACO team. Patients are supported at transitions of care in the acute care, rehab, skilled nursing facility, homecare, community and physician practice setting to optimize quality/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 primary care physician and patient to develop collaborative care plans to improve self-management of chronic conditions 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 utilizes critical thinking and creative problem solving skills to deal with complex care management needs in developing a patient-centered care plan.

Essential Duties & Responsibilities (including but not limited to):

Ambulatory Care Management: the Care Manager supports the primary/specialty care physicians in population health management by focusing care coordination attention on the high to moderate risk, chronic condition population driving utilization and costs to improve efficiency, quality and patient satisfaction.

Engages physician and practice team in proactive patient management by addressing medical and behavioral health care needs, follow-up, and referrals. Utilizes high risk registry, Lahey Hospital census reports and other reports provided by the MCOs to outreach to targeted population benefitting from care management program.

Offers and coordinates care consultation to complex patient/caregiver in the practice setting or home as necessary to reinforce disease management education utilizing teach back methods or assist with completion of health care proxy, advanced care planning, or community resource navigation.

Develops comprehensive care plans in collaboration with patient, physician and health care team based on evidence-based best practices for chronic illness care. Participates in creation of a patient-centered care plan that addresses problems /barriers/goals and develops action plan relevant to obstacles in chronic condition management. Refers patients to appropriate community resources and support programs, and ensures that patients are able to access and follow through on these referrals.

Ensures assessment and comprehensive care plans on the designated LTSS and BH populations are completed/signed by provider within required timeframe in compliance with LMH-ACO standards. Adheres to all LMH-ACO policy and MCO partner delegation requirements.

Serves as a central resource for the physicians and practice team for the LMH-ACO population functioning as navigator, coach, and disease manager for the targeted patient population. Collaborates with patients to facilitate healthy behaviors. Utilizes coaching to foster healthy diet, exercise, medication and disease management. Helps patients to learn strategies and skills designed to stabilize symptoms and prevent disease progression. Works closely with the community health worker to provide ongoing patient support reinforcing the care plan.

Reviews high cost patients with physician and/or primary care team to understand drivers of cost, current treatment plan, future course and prognosis. Ensures advance directives and appropriate referrals are addressed such as palliative/hospice and makes recommendations for cost reduction alternatives whenever appropriate.

Analyzes retrospective/concurrent utilization and cost data and seizes opportunity to reduce gaps in care by making recommendations for efficiency, quality and cost improvement. Understands organizational goals and accountability towards maximizing organization performance.

Communication: the Care Manager interfaces regularly with patients, families, assigned physicians, the health care team, community agencies, vendors, MCO partners, BH and LTSS Community Partners, and hospital staff as necessary to ensure efficient, quality care delivery.

Reviews high risk cases with Manager of Care Management, LMH-Medical Director as appropriate, and physicians in a concise, effective, professional manner. Addresses medical /and or psychosocial concerns and makes recommendations to improve efficiency and quality care. Serves as a resource to physicians, provider care team, and patient/family regarding inpatient/outpatient resources.

Documents in the case management system the assessment and clear, concise, timely notes that address patient medical/psychosocial problems, barriers, goals, support system, advance directives, transition plan and case management interventions to improve efficiency, quality and reduce cost.

Acute Care Management: the Care Manager is responsible for managing and ensuring safe and smooth care transitions across the continuum of care for the LMH-ACO patient population.

Performs timely and accurate daily case reviews targeting the chronic, high risk unplanned admissions/discharges, ED activity at home hospitals to identify plan of care and opportunities to provide transition support, improve gaps in care and prevent readmission. Utilizes non-home hospital census report if available to provide transition support to patients seeking care outside of Lahey system to ensure redirection back to local primary/specialty provider network.

Interfaces daily with LMH ACO interdisciplinary team to proactively address patient discharge needs, ensure appropriate level of care and streamline patient care transition across care settings.

Provides telephonic and/or face to face patient encounter to introduce care manager role and begin patient engagement. Completes comprehensive assessment with patient/caregiver to ensure vital transition components addressed such as medication concerns, social support system, advance directives as appropriate and BH and/or LTSS service needs. Refers to LMH-ACO social worker, BH clinician, pharmacist and community health worker as appropriate.

Utilizes motivational interviewing to engage patient in dialogue concerning unplanned admission while addressing chronic condition self-management. Reinforces education concerning chronic condition management utilizing evidence-based education tools.

Coordinates timely follow-up with primary or specialty physician to reduce gaps in care and reduce readmission risk. Coordinates VNA, DME and other community services to ensure a safe transition plan.

Proactively screens and refers patients to pharmacist with medication concerns to address cost-effective alternatives and promote medication adherence.

Provides transitional care calls within 2 business days of discharge to targeted patient population post hospitalization, post-acute care and ED visit to ensure timely follow up with primary/specialty care. Assesses home status, reinforces transition plan and addresses urgent care needs. Proactively intervenes when problems identified with prompt physician communication, access to care and coordination of services.

Participates in daily/weekly huddles with LMH-ACO interdisciplinary team to identify targeted population priorities to support efficient daily workflows and address barriers.

Patient and Provider Satisfaction: the Care Manager strives to provide quality patient and provider experience while working in collaboration with the patient/family and primary/specialty care physician team.

Coordinates care to maximize the value of services delivered to patients to improve health care outcomes.

Incorporates shared decision making in all aspects of patient care interactions. Promotes patient autonomy and self-management at every encounter.

Creates a culturally sensitive care plan while utilizing health literacy and language appropriate patient education materials to promote engagement in plan.

Quality Improvement: the Care Manager is responsible for timely reporting of quality events in the inpatient/outpatient care setting to ensure continuous monitoring for quality improvement.

Refers quality/risk management cases to Manager of Care Management, LMH-ACO Medical Director and Executive Director, and reports events per Lahey policy, regulatory and /or health plan requirements.

Identifies opportunities to improve patient compliance with LMH-ACO quality measures. Reports and follows up on patient complaints to ensure quality care and patient satisfaction.


Minimum Qualifications

Education: BSN required. Masters in a health or business field preferred.

Licensure, Certification & Registration: Active, unrestricted Massachusetts Registered Nurse License required. Certified Case Manager (CCM) required.


RN with BSN and 5 years minimum of both case management and nursing experience.

Excellent clinical, interpersonal and communication skills. Must be able to work collaboratively with other healthcare professionals as well as independently. Experience with coaching while working with the chronic, complex population in a physician management service organization is desirable.

Must be proactive, assertive, and possess creative problem solving skills.

Experience in with Mass Health population highly desirable. Experience with ACO, managed care, medical home or integrated case management environment is preferred.

Must be proficient in computer skills, internet, information technology and electronic medical record use.

Experience with Epic system highly desirable.

Skills, Knowledge & Abilities:

Strong development, analytic and systems building skills.

Must be facile with physician relations, developing systems and procedures, continuous quality improvement, human resources management and fiscal management.

Excellent written and verbal communication skills. Must have an executive demeanor and the ability to deal with physicians, senior management, local industry, payer organizations

Capable of serving as a spokesperson and leader of the integration process and communicate the vision to others in the community.

A well-defined style that demonstrates confidence, maturity, self-motivation, high energy, collaboration, high intellect and leadership qualities.

Excellent interpersonal skills, be an appropriate risk taker, politically savvy, diplomatic, able to deal with ambiguity, flexible, organized, results oriented, a hard worker, a quick study, good with details and have integrity.

Ability to function as a facilitator who can further the organization to serve the evolving Network.

Other Job Requirements

Schedule Requirements: Some flexible work hours to accomplish member outreach and engagement at times when members are reachable; this may involve some early evening hours or later work days.

Travel Requirements: Must have a current, valid driver's license and own transportation. Travel and an ability to meet with members served in a variety of outreach settings is required.

O-About Us

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.