Transitions of Care RN Care Manager

Site: Mass General Brigham Community Physicians Inc.

Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a not-for-profit we support patient care research teaching and community service striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

Across the country governments employers and American families have struggled in the face of rising healthcare costs. Efforts historically have targeted narrow programs and patient populations and while many have succeeded healthcare costs continue to rise. Its time to take a radically different approach. A new approach involves putting the patient at the center with the goals of improving value and providing better outcomes at lower cost for patients. The Population Health Management (PHM) department at Mass General Brigham is charged with the challenge to drive better value for patients across Mass General Brigham. To achieve its goals PHM leverages financial and clinical data to examine opportunities designs and delivers innovative care models using product development and design thinking disciplines and leverages problem solving teamwork and leadership skills to drive ongoing improvement.

As an integral member of the Population Health Management Operations team The Transition of Care Nurse Care Manager provides episodic care management for Medicare Shared Savings Program (MSSP) and Medicaid ACO patients from inpatient admission to home. This includes follow up phone calls after discharge medication reconciliation and ensuring patient has appropriate follow up appointments scheduled as well as documenting and ensuring all billing requirements are met prior to submitting TCM charges. The Transition of Care Nurse Manager directly interfaces with patients (via phone) Primary Care physicians pharmacists care managers and health care teams involved in patient care as well collaborating with PHM Clinical Operations leadership.

Primary Responsibilities:

1. Manages episodic transitions of care for Medicare Risk and Medicaid risk patients from inpatient discharge to home as applicable.
a. Calls all discharged patients within two business days of discharge and conducts post discharge assessments.
b. Works alongside the PHM Clinical Pharmacist to identify and perform Medication Reconciliation for identified patients within the two day follow up phone call.
c. Reviews discharge instructions/paperwork prior to call to review with patient any action items needed prior to follow up appointment.
d. Facilitate face to face follow-up appointment with their PCP within 7-14 days after discharge (or according to discharge instructions if applicable).
e. Document patient interaction (phone calls) in the appropriate patient chart in the electronic medical record.
f. Manages and coordinates transitions of care by communicating the care plan to other providers and care managers and applicable practice staff.
g. Maintains all documentation according to standards and requirements.
h. Ensures all Transitions of Care (TCMs) meet appropriate billing requirements prior to submitting documentation to the billing department per protocol yet TBD.

2. Demonstrates effective teamwork and collaboration with the primary care provider and the care team
a. Engages the patient and caregiver as active members of the care team and facilitates an organized and effective warm hand off for transitions of care back to the patients medical home (PCP).
b. Participates in regular meetings with the providers and the care team to identify opportunities for better transitions or to modify workflows as needed.
c. Communicates with other PHM and (Regional Service Operation (RSO) departments and sites to foster collaboration as a system around the patients served.

Organizational Responsibilities:

a positive attitude in dealing with patients co-workers and other health care providers and in addressing problems and/or crisis situations.
the ability to work independently as well as function effectively within a team-based model of care.
to establish collegial relationships with physicians office staff and health care providers in physicians offices community agencies hospitals and other health care facilities.
within the patient centered model of care demonstrates a commitment to meeting the patients needs and expectations.
within the team-based model of care
initiative and creativity to continuously improve services work processes and other activities that affect quality and utilization.
applicable policies and procedures for general safety fire safety infection control attendance punctuality and appearance.
all duties as assigned.

Other Duties and Responsibilities:

accountability for professional growth and development.
as a role model for patients by practicing behaviors consistent with the program goals of health promotion and disease prevention.
quality of care issues and reports the concerns to the appropriate person.
prepares and reports data as directed.
in preparation for external audits and surveys as applicable.

Qualifications

• Required:

  • Associates Degree Nursing (ASN) or Bachelors Degree Nursing (BSN).

  • RN License for State of MA.

  • 3 years of experience in hospital health plan or community case management or utilization management role.

  • Care management or home care background.

  • Managed Care or previous healthcare reimbursement knowledge.

• Preferred:

  • Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.

  • Certification in Case Management (CCM) and/or other applicable professional certification preferred.

  • Previous experience working in a post-acute setting such as LTAC acute rehabilitation skilled nursing facility or homecare.

  • Bedside nursing experience.

Additional Skills Knowledge and Abilities:

- Excellent organizational skills.

- Excellent oral written and telephonic skills and abilities.

- Critical thinking and problem-solving ability.

- Demonstrated ability to present and speak in front of groups.

-Demonstrated competency working with health care setting computer systems.

-Competence in Microsoft Word Excel and PowerPoint.

-Ability to work effectively with physicians and their staff in a physician practice setting.

-Ability to work a flexible schedule including some required evenings or early mornings.

-Knowledge of levels of care and the continuum of health care services.

-Ability to handle routine work unexpected priorities and multi-task.

-Requires autonomy in decision making using sound judgment based upon

factual information clinical experience and nursing process.

-Ability to work with various practice sites.

Schedule and Work Model

• Full-Time Monday through Friday standard business hours (approximately 8:30am-5pm ET)

• Remote with ability to travel to Assembly Row in Somerville MA for team building best practice sharing meetings and/or events.

• As a remote employee must use a stable secure and compliant workstation in a quiet environment. Teams video is required and must be accessed using MGB-provided equipment.

Remote

399 Revolution Drive

40

Regular

Day (United States of America)

Pay Range

$58656.00 - $142448.80/Annual

Grade

98TEMP

At Mass General Brigham we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive and any offer extended will take into account your skills relevant experience if applicable education certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however it does not encompass all elements contributing to your total compensation addition to competitive base pay we offer comprehensive benefits career advancement opportunities differentials premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

6010 Mass General Brigham Community Physicians Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religious creed national origin sex age gender identity disability sexual orientation military service genetic information and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process to perform essential job functions and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973 the Vietnam Veterans Readjustment Act of 1974 and Title I of the Americans with Disabilities Act of 1990 applicants who require accommodation in the job application process may contact Human Resources at .