The ACO Nurse Care Manager is responsible for the management of care for a defined group of patients including complex care management, transitions of care, as well as coordination of care. Major responsibilities include accurately identifying patients for care management, developing individualized plans of care, assessing/addressing barriers to care, medication reconciliation, medication titration as well as ensuring adherence to quality measures. The goal is to work with patients to optimize control of chronic medical and mental health 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. Appropriate documentation in patient medical records and/or care management application is required and is vital.
Assumes accountability for own professional practice and for aspects of patient care delegated to others. Practices within the ethical and legal parameters of nursing practice. This description covers the essential functions of the position. Incumbent is expected to perform other similar and related duties as assigned.

Job Responsibilities: 

• Coordinates, oversees and directs the interdisciplinary team members to provide care that is safe, timely, effective, efficient, equitable, and client-centered to the assigned patient population.
• 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.
• Promotes quality and cost-effective interventions and outcomes to patients in collaboration with the primary care providers and/or specialists.
• Manages transitions of care for patients discharged from the hospital, behavioral heatlth facility/program, 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.
• Providing disease management/complex care management to patients face to face or telephonically as well as utilizing technology that becomes available. Providing home visits to patients when appropriate. Titrating medications via protocols when necessary.
• Overseeing Care Coordinators and Community Health Workers 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, availability of community resources and quality improvement methodologies
• Appropriate documentation in patient medical records and/or care management application is required and is vital. Care management program metrics including, emergency room utilization, and hospital admission/readmission data will be reviewed on a regular basis.
• Develops and collects data to identify trends in utilization of health care resources.
• Assumes accountability for own professional practice and for aspects of patient care delegated to others.
• Practices within the ethical and legal parameters of nursing practice.
• Home visits

Required Work Experience: 

• Massachusetts RN License, Drivers License and BLS CPR
• Minimum of 4  years of nursing experience
• A minimum of 2 years care management and or community health experience
• Strong communication, interpersonal and problem solving skills to advocate for optimal patient outcomes.  Capacity to work closely with patients, physicians and their office staffs and managed care plans.  Strong organizational and prioritization skills.  Attention to detail and able to perform work independently. 
• Excellent verbal and written communication and interpersonal skills. Bilingual skills preferred
• Reliable transportation and valid drivers license

Location - Supporting our Community Health Centers