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Integrated Care Nurse
Category: Other
  • Your pay will be discussed at your interview

Job code: lhw-e0-89770969

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  Job posted:   Thu May 17, 2018
  Distance to work:   ? miles
  1 Views, 0 Applications  
Integrated Care Nurse


Job Description
The Clinical Care Manager (CCM) is a RN who provides intensive care coordination and clinical care management for MassHealth Members with complex medical and behavioral health needs who are enrolled in an Accountable Care Organization (ACO) or Managed Care Organization (MCO) plan.
The CCM collaborates with their respective Community Partner team and the clinical staff of each Enrollee's ACO/MCO's plan to minimize duplicative efforts, promote integrated care, ensure quality and continuity of care, and support the values of person centered planning, Community First and SAMHSA Recovery Principles. The CCM is at the helm of organizing and coordinating resources and services in response to the Enrollee's healthcare needs across multiple settings, and inclusive of both LTSS and Social Determinants of Health (SDH) needs. This role drives outreach and engagement, assessment and care planning, care transitions, health and wellness coaching, as well as community and social services connections in partnership with Enrollees and their care teams.
* Outreach to and engage enrollees enrolled in ACO and referred for CP program
* Conduct comprehensive assessment of enrollees including the medical, psychiatric and social issues of enrollees served
* Review/sign off on medical component of comp assessment of Care Team enrollees;
* Organize and facilitate the effective functioning of the Interdisciplinary Care Team (ICT), including coordinating meetings, facilitating communication and documentation
* Monitor the enrollee's health status and needs and provide nursing and medical care coordination, including revising health related treatment goals and plans in collaboration with the enrollee and the team
* Coordinate the development, implementation, monitoring and review of the enrollee care plans, including health care strategies
* Collaborate closely with PCP and other Providers including, but not limited to community resources, and assure appropriate referrals based on level of care needed to optimize outcomes and minimize risk
* Collaborate with ACO Plan, PCP and other health care Providers regarding changes in services, care transitions, crisis intervention; while focusing on continuity and quality of enrollee care and potential efficiencies and cost-savings;
* Conduct medication reviews and reconciliation including adjustment by protocol
* Communicate and collaborate with ACO teams and serve as a team resource
* Follow up of an enrollee's admission to a planned or unplanned medical or psychiatric inpatient stay, (including hospital, Rehab facility, shelter, substance abuse programs), and collaborate with enrollee, care team staff, ICT and hospital staff to coordinate safe inpatient discharges;
* Minimum of 5 years clinical and case management experienced preferred.
* Registered Nurse licensed in Massachusetts (RN, BSN or MSN) in Massachusetts
* Effective skills in managing, teaching, negotiating, and collaborating with multidisciplinary teams and enrollee/family focus.
* Experience working with people with psychiatric disability, co-occurring disorders preferred.
* Preference given to bi-lingual/bi-cultural applicants and applicants with lived experience of psychiatric conditions.
Monday - Friday 9 am - 5 pm
*City:* Somerville
*State:* Massachusetts
*Region:* Greater Boston Area
*Pay Rate:* $70,000 / year (RN)
*Standard Hours per Week:* 40
*Sign On Bonus:* $2000
*Driving & Vehicle Requirements:* License check and vehicle access required

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