Req#: R14775
Category(s): Nursing, Care and Case Managers
Full Time / Part Time: Full-Time
Shift: First

BAYCARE- Outpatient Nurse Care Manager is responsible for managing the complex patients (top 5%) that are included in the risk contracts. They are responsible for the management of care for this defined group of patients including complex care management, disease management, transitions of care, as well as coordination of care. The goal is to work with patients to optimize control of chronic conditions, improve functional status, reinforce self-management plan and prevent/minimize long-term complications as well as to avoid unnecessary emergency room visits or hospital admissions. They will work collaboratively with physicians and other health team members along the patients continuum of care, and are available to patients and families for care coordination/education through face to face visits, home visits if necessary, as well as telephonic interactions. In addition, they will assist with advance directives, palliative care, hospice, and other end-of-life care coordination.

• Responsible for coordinating and providing care that is safe, timely, effective, efficient, equitable, and client-centered to the patients in the risk contracts.
• Responsible for appropriately identifying patients for care management utilizing multiple sources including physician referrals, referrals from transitions of care, health plans as well as complex lists of patients from the ACO.
• Conducts whole person assessments to determine individual patient needs and create individualized self management plans of care in conjunction with the patient/family. Evaluate the effectiveness of the plan of care and revise as necessary to meet goals.
• Assists patients to make informed decisions about their care by acting as their advocate regarding their clinical status and treatment options.
• Manages transitions of care for patients discharged from the hospital, emergency room, or from a skilled nursing facility. Responsible to review the discharge summaries, follow up on testing that is pending, ensure ordered services are in place. Outreaching to the patients to perform a medication reconciliation, ensure patients understanding of discharge instructions and assess for further care management needs.
• Overseeing population management activities with the Care Coordinators which includes addressing quality indicators that are out of range and assisting patients to reach targets.
• Accountable for remaining current with knowledge of care management, including population management, availability of community resources and quality improvement methodologies.

Required Work Experience: 

• Registered Nurse in the State of Massachusetts.
• 5 years clinical nursing experience required
• Valid Drivers License
• Bachelor’s Degree preferred.
• Outpatient nursing and / or care management experience strongly preferred
• Experience with educating patients and patient goal setting is essential as is problem solving skills to advocate for optimal patient outcomes  Qualified candidates must have excellent written and verbal communication and interpersonal skills and ability to work independently

Other Information:

• Hours- Full Time 40 hours Monday – Friday.
• Locations- Baystate Primary Care Westfield and Family Medicine Associates- Westfield
• Resume required

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.

DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.

Education:

Associates of Science: Nursing (Required), Bachelor of Science: Nursing

Certifications:

Basic Life Support – American Heart Association, Driver License – Other, Registered Nurse – State of Massachusetts

Equal Employment Opportunity Employer

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