OB High Risk RN care Manager (4115)

About the position As an integral member of the care management team the Nurse Care Manager (CM) will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic conditions, many of whom also face multiple barriers in their lives which makes it difficult for them to achieve the self-care required to improve their health and well-being. This position requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in person in a variety of potential settings such as but not limited to, the health center, community, home, or an inpatient facility. This role is currently hybrid with potential travel to FQHCs required. The Nurse Care Manager/Maternal Newborn supports high risk pregnant and post-partum members who are at-risk for an adverse delivery based on complex social, behavioral and health needs with consideration of all levels of healthcare disparity. This CM provides ongoing management of the mother and newborn for 12 months post-partum, 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 a care plan to enhance the member’s overall prenatal/postpartum health, and to achieve appropriate utilization. They will also assess plans, implement, coordinate, monitor, and evaluate care plans, services, and outcomes to maximize the maternal/child health of the member.

Responsibilities

• Conducts Comprehensive Assessments
• Assures that medication reconciliation is complete. The RN CM will complete the medication reconciliation and may include a pharmacist and/or primary care team.
• Engages members and care givers in active care planning with focus on medical, behavioral, social, member-centered care needs.
• Coaches and guides member/representative 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.
• Travel throughout assigned area to engage members at their homes 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.
• In collaboration with Community Health Workers, creates and maintains a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services.
• Participates in the integrated care team meetings and rounds as required
• Maintain accurate, timely documentation in electronic systems including health center EHRs.
• Provides coverage for team members who are out of office
• Other duties as assigned

Requirements

• Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Social Workers, Community Health Workers and other health care teams.
• 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
• Must demonstrate excellent interpersonal communication skills
• Experience using appropriate technology, such as computers, for work-based communication
• Experience and proficiency with Microsoft Office and online record keeping
• Licensed Practical Nurse (LPN) with Care Management experience, ASN (associate degree in nursing) or bachelor’s degree in nursing (preferred)
• Current, active MA Nursing license
• Minimum 2-5 years of nursing experience in Maternal/Newborn or Post-partum required, community public health, case management, coordinating care across multiple settings and with multiple providers also recommended.
• A valid driver's license and provision of a working vehicle
• In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law.

Nice-to-haves

• Additional qualities that would be a good fit for our team include: Enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a ‘go with the flow’ attitude
• MassHealth C3 ACO Key Performance Indicators (KPIs): Based on 1.0 Full Time Employee CM: Annual Enrollment is 200 patients per year. Monthly Enrollment a minimum of 17 patients. Average Case Duration is (1 year postpartum). (These requirements are based on the C3 Delegation Agreement with BNHC and are subject to increase.)
• Familiarity with the MassHealth ACO program
• Familiarity with Federally Qualified Health Centers
• Experience with anti-racism activities, and/or lived experience with racism is highly preferred
• Case Management Certification (CCM, ANCC RN-BC) preferred.

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