Nurse Navigator Care Manager

Location: Burlington, MA
Job ID: 160710-1A
Date Posted: May 12, 2020
Category: Nursing

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Job Description

Welcome To

Welcome to Beth Israel Lahey Performance Network (BILPN). BILPN is a clinically integrated network of physicians, clinicians and hospitals committed to providing high-quality, cost-effective care to the patients and communities they serve, while effectively managing medical expense. Leveraging best practices in population health management and data analytics, BILPN will improve care quality and patient health outcomes across the system through population health initiatives. BILPN brings together the expertise of Beth Israel Deaconess Care Organization, Lahey Clinical Performance Network, Mount Auburn Cambridge Independent Practice Association and affiliated providers across eastern Massachusetts who all share a common goal to achieve success in a value-based delivery system.


About the Job

Beth Israel Lahey Health Performance Network (BILHPN) is responsible for oversight of Care Management within BILHPN value based contracts.  Tufts Medicare Preferred (TMP) and BILHPN have partnered to create a unique Nurse Navigator role to focus on TMP membership receiving care within Lahey Hospital and associated Lahey medical groups.  This role will work closely with the designated medical director to improve care coordination and appropriate, safe and timely discharges for the TMP population.

Responsibilities include working with physicians, patients, families, and the multidisciplinary team in the acute care setting (75%) and ambulatory setting (25%).  The Nurse Navigator assesses, plans, and coordinates with the inpatient and ambulatory medical management teams to evaluate and implement services that meet the individual patient needs.

Success will be measured through the measurement of successful transitions and readmissions, as well as quality measures related to advanced care planning and follow-up care.  Must be able to effectively work in a matrixed collaborative environment, working directly with internal and external stakeholders at all times.

Essential Duties & Responsibilities including but not limited to:

The Nurse Navigator is responsible for managing and ensuring safe and smooth care transitions across the continuum of care for the Lahey TMP patient population.

Performs timely and accurate daily case reviews targeting the chronic, high risk unplanned medical admissions at Lahey hospital to identify admission rationale, plan of care and opportunities to improve gaps in care and prevent readmission.

Interfaces with multidisciplinary team including TMP Medical Director/Hospitalist, hospital case manager, physical therapy, VNA, pharmacy, social work and others to proactively address patient/caregiver transition needs, to ensure appropriate level of care and enhance patient care transitions across care settings.

Provides face to face patient encounter to introduce case 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, service and transportation needs. Addresses routine preventive care at every patient encounter.

Work with primary care teams in the outpatient setting as a liaison to TMP case management. Identify opportunities for improved care coordination for high risk members

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. Refers patients to social worker to address social needs.


Minimum Qualifications:

Education:           Registered Nurse required.  Bachelors prepared or higher preferred.

Licensure, Certification & Registration:   Active Massachusetts Registered Nurse License required.

Preference to candidates with Case Management certification from one of the following:

•             American Case Management Association (ACM)

•             Certified Case Manager (CCM), Certified Professional in Healthcare Management (CPHM) or

•             Case Manager Administrator (CMAC)

Experience:        Experience in a Population Health or Inpatient Care Management environment required

Skills, Knowledge & Abilities:      

1.            >5 years of experience in Care Management.

2.            Possesses strong influencing and relationship-building skills.  Agility in communicating effectively, including a wide range of departments and individuals at all levels through the organization.

3.            Excellent verbal presentation skills as well as ability to write in a clear and concise manner.

4.            Proven effectiveness in working with senior clinical and administrative leadership as well as front line staff.

5.            Creative and strategic thinker with a flexible and collaborative style.

6.            Strong development, analytic and systems building skills.

7.            Must be facile with physician relations, developing systems and procedures, developing and operating a capitated managed care infrastructure, continuous quality improvement, human resources management and fiscal management.

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

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

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

11.          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.

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

About Us

Beth Israel Lahey Health is an integrated system providing patients with better care wherever they are. Care informed by world-class research and education. We are doctors and nurses, technicians and social workers, innovators and educators, and so many others. All with a shared vision for what healthcare can and should be. We are committed to attracting, developing and retaining top talent. We strive to create a diverse and inclusive workplace that reflects the communities in which we work and serve. With a team approach to care, we encourage learning and growth at all levels and offer competitive salaries and benefits.

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.