Complex Care Manager - RN, HIV Services

Job Description

As a central member of the patients’ multidisciplinary heatlh care team, the Complex Care Manager (CCM) will be a Registered Nurse who identifies and engages patients with a focus on improving patient experience, improving health and reducing costs.  Care management of complex patients is the deliberate organization of patient care activities to facilitate optimal delivery of health care services.  Organizing care involves a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs.  This is managed by the effective exchange of information among all participants on the care team, including the patient.  Complex care management involves the oversight and coordination of care delivery targeted to high risk patients with diverse combinations of health, function and social problems.  Excellent interpersonal skills, patient engagement skills and the ability to work indenpendently and collaboratively are key requirements of the role.

Provide care management services for highly complex patients within the health center.  Utilizing a high-risk patient registry and Primary Care Provider (PCP) input, the Complex Care Manager will identify the patients, perform risk stratification and conduct comprehensive assessments.  The CCM will then work with the care team, and also independently, to develop a comprehensive, proactive, evidenced-based integrated care plan (ICP).  The CCM will be responsible for managing an active case load, as well as maintaining a registry of complex patients.The Complex Care Manager is responsible for working with patients to identify strengths and barriers and develop an individualized, patient-centered plan of care. 

Essential Duties and Responsibilities

The assigned duties and responsibilities include, but are not limited to:

General

• Identify patients with medical, behavioral, functional and social complexity.
• Perform risk stratification and maintain a patient registry for identified complex patients.
• Assess the healthcare, educational, functional, psychosocial needs of the patient/caregiver.
• Develop a comprehensive individualized ICP, in collaboration with the patient/family and care team.
• Continually monitor the care plan and revise as indicated.
• Comprehensive assessment to include bio-psycho-social-spiritual-cultural.
• Addresses psychosocial barriers to health and optimal self-management.
• Coordination and collaboration with primary care team.
• Monitor adherence to treatment plans, self-monitoring, scheduling necessary appointments.
• Assess, and provide support for, patient self-management.
• Maintain all required documentation of activities.
• Provide consistent communication to the care team to evaluate patient/family status.
• Closely supports patient through transitions of care.
• Attend medical and specialty appointments with patient when appropriate.
• Collaborate with PCP and others on the health care team to ensure flow of important information to include regular updates to the care team via case conferences, e mail or phone.
• Facilitates interdisciplinary consultation on patients’ behalf through participation in PVP rounds, team meetings and clinical reviews.
• Facilitates complex care clinical review meetings.
• Medication reconciliation and referral to pharmacy resources as appropriate.
• Assists patients when necessary in placing calls, completing applications, and advocating for available services.
• Assists in coordinating activities with Community Health Workers (CHWs)
• Ensure information and reports clearly describe progress.
• Coordinate care through collaboration with the care team.
• Implement care using evidence based clinical guidelines.
• Attend appropriate staff and community meetings, such as, daily huddles, CCM meetings as scheduled and case conferences as needed.
• Participate in Quality Improvement activities as assigned.

Assumes any and all duties and responsibilities consistent with above and as assigned.

Qualifications

Knowledge

• Current Massachusetts license as a Registered Nurse required. CPR Certificate required.
• Bachelor’s degree in Nursing required.Master’s degree strongly preferred.
• General computer knowledge: Microsoft Outlook, Office, Excel.
• Use of Electronic Medical Record required

 Experience

• 1-3 years of experience working as a Registered Nurse in an ambulatory care setting required. 1-3 years of experience working with people affected by HIV preferred.
• Care management, or similar experience with special populations, preferred.

Additional Information

All your information will be kept confidential according to EEO guidelines.