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Readmissions Complex Care Manager

Company: Boston Medical Center
Location: Waltham
Posted on: May 23, 2020

Job Description:

Boston Medical Center (BMC) is more than a hospital. Its a network of support and care that touches the lives of hundreds of thousands of people in need each year. It is the largest and busiest provider of trauma and emergency services in New England. Emphasizing community-based care, BMC is committed to providing consistently excellent and accessible health services to all—and is the largest safety-net hospital in New England. The hospital is also the primary teaching affiliate of the nationally ranked Boston University School of Medicine (BUSM) and a founding partner of Boston HealthNet – an integrated health care delivery systems that includes many community health centers. BMC provides a full range of pediatric and adult care services, from primary to family medicine to advanced specialty care. BMC is also committed to our employees, who are a very important piece to who we are. We pride ourselves in providing equal employment opportunity and non-discrimination for all employees and qualified applicants without regard to a person’s race, color, gender, age, religion, national origin, ancestry, disability, veteran status, genetic information, sexual orientation or any characteristic protected under applicable law. BMC will make reasonable accommodations for qualified individuals with known disabilities, in accordance with applicable law. This position will work with relevant stakeholders to identify and engage patients in care management with a focus on patient experience, improving health, and reducing cost. This individual is responsible for working with patients, families and inpatient/outpatient providers to develop an individualized, patient-centered care plan focused on addressing medical and psychosocial factors in order to reduce hospital readmissions. The individual is responsible for direct patient care for patients requiring clinical intervention. Clinical expertise as a nurse practitioner or experienced registered nurse in common high-risk medical conditions (e.g. CHF, diabetes, COPD, etc.) as well as excellent interpersonal skills, patient engagement skills and the ability to work independently and collaboratively are key requirements of the job. About this position: • Based upon the identification of at-risk patients via the high risk assessment tool, visits hospitalized patient prior to discharge/ transfer to establish relationship, and leads the clinical care team to complete the following: • Comprehensive bio-psycho-social-spiritual assessment • Development of patient-centered care plan in collaboration with patient and care team, with particular focus on chronic disease management, social determinants of health, transitions of care, and advance care planning • Implementation of care plan both during and after admission • Patient and family education on chronic disease management and self-engagement • Close communication with outpatient and inpatient care team providers throughout care transition • Collaboration with community partners, such as VNA agencies, caregiver programs (PCA, ADH, AFC), DME providers and social service agencies • Assessment of goal completion with transition of patient to outpatient providers as appropriate • Possess knowledge of common chronic medical conditions presented in the population served and is able to: • Educate the patient on their medication conditions and medications, and build their self-management skills; • Identify medications that may need adjustment in collaboration with the PCP, inpatient care team, and/or subspecialist partners; • Use motivational interviewing to promote behavioral change; • Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon. • Documents and maintains patient-specific records/data in EMR system Collaborates with the Emergency Department, inpatient, outpatient and community social workers to support the patients and providers participating in the patient care. • Follows established hospital infection control and safety procedures. Conforms to hospital standards of performance and conduct, including those pertaining to HIPAA standards and confidentiality of protected health information, patient rights, and BMC’s RESPECT behavioral standards Utilizes hospital’s cultural beliefs as the basis for decision making and to support the hospital’s mission and goals. Complies with established metrics for performance and adheres to documentation and work flow standards • Performs other duties as requested or needed. EDUCATION: Graduate of an accredited BS program in Nursing CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED: • Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts. • AND/OR • Masters’ Degree in Nursing • Completed an accredited educational program for Nurse Practitioners • Certification in NCM/CCM preferred EXPERIENCE: • A minimum of four years of clinical experience is required, with care management experience preferred. • Ambulatory primary or specialty care and Inpatient care • Motivational interviewing • Clinical experience working with patients with multiple complex health issues • Care management Pandologic. Category: , Keywords: Hospital Manager

Keywords: Boston Medical Center, Waltham , Readmissions Complex Care Manager, Other , Waltham, Massachusetts

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