ACO Nurse Care Manager Job Category: Healthcare Support Requisition

Number: ACONU001082 Full-Time On-site Springfield, MA 01103, USA

\*\*\*\* 10,000 SIGN-ON BONUS\*\*\*\* The Nurse Care Manager provides

complex care management, connecting members with appropriate social

services and promoting self-management of their behavioral and medical

needs. The Nurse Care manager is a key member of an interdisciplinary

team in the development and implementation of care plans to enhance the

member\'s overall health and to achieve appropriate utilization of

services. They will also assess plans, implement, coordinate, monitor,

and evaluate care plans, services, and outcomes to maximize the health

of the member. Qualifications: Licensed Practical Nurse (LPN) with Care

Management experience, Associate degree in Nursing (ASN) or Bachelor\'s

degree in Nursing, BSN (preferred) Current, active MA Nursing license

Minimum 2-5 years of nursing experience in community public health, case

management, coordinating care across multiple settings, and with

multiple providers is also recommended. Case Management Certification

(CCM, ANCC RN-BC) preferred. A valid driver\'s license and provision of

a working vehicle. Required Skills: Demonstrated success in working as

part of a multi-disciplinary team, including communicating and working

with Providers, Pharmacists, Social Workers, Community Health Workers,

and other health care teams. Experience within the ACOs member

population preferred, including Medicare/Medicaid Ability to flexibly

utilize clinical expertise to solve complex problems. Bi/multi-lingual

Preferred Or Experience With Language Translation Services Experience

working with patients with chronic and behavioral health needs. Must be

flexible and adaptable to change. Demonstrate the ability to work

independently with licensure support and oversight where applicable.

Must demonstrate excellent interpersonal communication skills.

Experience using appropriate technology, such as computers, for

work-based communication. Other Desired Skills: Familiarity with the

MassHealth ACO program Familiarity with Federally Qualified Health

Centers Principal Responsibilities and Duties: Conducts Comprehensive

Assessments Ensures that medication reconciliation is complete. The

Nurse CM will complete the medication reconciliation and may include a

pharmacist and/or primary care team. Engages members and caregivers in

active care planning with a focus on medical, behavioral, social, and

member-centered care needs. Coaches and guides members/representatives

to meet bio/psycho/social goals. Provide care coordination, which may

include, but not limited to, facilitating care transitions, supporting

the completion of referrals, and/or providing or confirming appropriate

follow-up. May be required to meet members while they are inpatient to

provide education and support about the discharge process and transition

members into care management. May need to travel throughout the assigned

area to engage members at their homes, at the health center, or other

locations where the member may be located. Assesses the member\'s

knowledge of their medical, behavioral health, and/or social conditions

and provides education and self-management support, including symptom

response plans based on the member\'s needs and preferences. Connects

members with primary care, behavioral health, flexible services,

Community Partner, respite, and other community-based social services as

indicated and appropriate. Participates in the integrated care team

meetings and rounds as required. Maintain accurate, timely documentation

in the Electronic Health Records (EHRs) Provides coverage for team

members who are out of the office. Other duties as assigned