Care Manager, Senior Care Options

Description:
Qualifications: Education:
• Registered nurse
• Bachelor's degree or an equivalent combination of education, training and experience is required.
Preferred/Desirable:
• Master's degree in nursing, geriatric NP, or health related/public health field preferred
• Certification in case management (CCM) preferred
• Bilingual Spanish, Haitian Creole, Spanish Creole, French Creole, other
Experience: 3 years' experience in Medical Case Management working with the geriatric population Certification or Conditions of Employment: • Pre-employment background check
• Active Massachusetts RN license required.
Certification or Conditions of Employment:
• Pre-employment background check
Competencies, Skills, and Attributes:
• Excellent clinical and assessment skills
• Experience with the Medicaid, Medicare, and Senior population
• Experience with ASAPs preferred
• Ability to work collaboratively and build strong relationships with providers, Enrollees, and the PCT
• Proficiency in InterQual Level of Care through the continuum
• Excellent working knowledge of Windows and Microsoft Office products
• Flexible, independent, self-starter with an ability to thrive in a fast paced environment
• Demonstrates commitment to quality
• Projects positive, team oriented demeanor
• Demonstrates strong interpersonal skills including effective listening and ability to support, motivate and guide others
• Strong oral and written communication skills; ability to interact within all levels of the PCT
• Demonstrated strong organization and time management skills
• Demonstrated ability to successfully plan, organize and manage within a person centered integrated care team
• Detail oriented Working Conditions and Physical Effort: • Regular and reliable attendance is an essential function of the position.
• Work is normally performed in the field and home office
• Attendance and participation at BMCHP in-office meetings are required
• Attendance and participation at PCT meetings required
• No or very limited physical effort required. No or very limited exposure to physical risk.
• Fast paced environment
• Travel within the SCO geographic network required

Responsibilities:
Job Summary: In this role, the Care Manager, Senior Care Options will perform a variety of diverse and complex face to face and telephonic care management responsibilities. The Care Manager's work will primarily be conducted in the field and working remotely/in a work from home environment. The Care Manager will act as the medical clinician link within the Primary Care Team (PCT) in partnership with the Enrollee, the Geriatric Supports Services Coordinator (GSSC), Beacon Behavioral Health Strategies staff, non-clinicians, pharmacists, medical directors and others. The Care Manager will be the medical lead for the team in the completion of assessments and re-assessments, and the development of the person-centered Individualized Plan of Care (IPC). The Care Manager will manage the Enrollee through the health care continuum, including acting as the liaison for hospital staff, community based organizations and Aging Services Access Points (ASAPS), the primary care provider and other members of the PCT.

Key Functions/Responsibilities:
• Completes initial and on-going face to face comprehensive assessment with Enrollees
• Demonstrates strong knowledge and use of the MDS-HC assessments to maximize placement of Enrollees into the appropriate rating category
• In conjunction with the Enrollee and the PCT develops a person centered Integrated Plan of Care
• Facilitates meetings of the PCT
• Utilizes evidence-based guidelines to assist Enrollees in understanding their disease process and increase their capacity for self-management and optimal health • Utilizes evidence-based guidelines to develop Individualized Plans of Care (IPC)
• Evaluates the effectiveness of the IPC and progress against goals
• Serves as designated medical clinical care subject matter expert on the PCT
• Evaluates the effectiveness of alternative care services and ensures that cost effective, quality care is maintained according to standards
• Facilitates linkage and referral to ASAPS and other community based organizations
• Documents clinical assessments and coordination of care in the medical management information system in a timely manner that meets regulatory and accreditation standards
• Ensures continuity of care through effective transition planning
• Provides culturally competent care coordination in keeping with the Enrollee's racial, ethnic and sexual orientation
• Utilizes data to ensure that clinical interventions result in improved clinical outcomes and appropriate utilization of services at the right time, right place, and right setting
• Facilitates sharing of essential clinical or psychosocial information related to the Enrollee's care
• Maintains HIPAA standards and confidentiality of protected health information. • Reports critical incidents and information regarding quality of care issues.
• Serves and participates in pertinent committees and meetings as needed
• Assists with new staff training • Regular and reliable attendance is an essential function of this position
• Must have the ability to use a laptop, or tablet for accessing the BMCHP systems to include documentation in the medical management information system
• Must use a cell phone and provide on-call services, per a rotating schedule
• Must become strongly knowledgeable in the full contractual requirements of the SCO Care Management agreement with EOHHS and CMS (D-SNP agreement) • Must become proficient in contracts with vendors and agencies of whom BMCHP outsources for the SCO population
• Must attend meetings at the BMCHP office(s), as requested by the Management team
• Must attend PCT meetings which may include early morning or evening meetings Supervision Exercised:
• None Supervision Received:
• Weekly supervision with Manager of Care Management, Senior Care Options

Comments/Special Instructions
-open to someone that we could consider for temp to perm. -position will have significant travel within the city of Boston as well as 3 other smaller cities within Suffolk County Massachusetts -position will be required to work in the Charlestown (Boston) office daily when not performing site visits. Position will allow for remote work flexibility but only once the worker is trained, up and running and performing well. Which will be determined by the manager at the time. We should be cautions to not over promise telework will be allowed so soon. -position should be comfortable doing site visits in urban/city environments -ideally this person would have experience working with a competitor SCO (Senior Whole Health, commonwealth care alliance, united/evercare, tufts or Fallon). though we are also open to folks that have prior exposure to completing MDS assessments, or home care along with care management.. ASAPs (Aging Services Access Points) are great targets too