About this role
Hybrid RN Care Manager - Greater Boston - $5K SIGN ON BONUS!
Job Summary
The Integrated Care Clinical Manager - Massachusetts is a community based registered nurse responsible for providing monitoring, follow-up and clinical care management to dually-eligible enrollees with complex medical, behavioral and social care needs. This position focuses on integrating health services and community resources to coordinate enrollee care for improve health outcomes and enhanced quality of life.
Essential Functions:
- Engage with the enrollee in their homes and other community settings to establish an effective, complex care management relationship, while considering the cultural and linguistic needs of each member.
- Function as a liaison between healthcare providers, community resources, and enrollees to ensure seamless communication and care transitions.
- Perform required assessments on a timely basis, including but not limited to Comprehensive Assessment, MDS-HC (or successor) Functional Assessments, and Crisis and Risk Assessments
- Engage enrollees in care plan development and implementation, providing routine updates as the enrollee’s status changes
- Lead the interdisciplinary care team (ICT) and collaborate with peers both internal and external to the organization, to create holistic care plans that address medical and non-medical needs.
- Oversee enrollee utilization of long-term services and supports, ensuring appropriate systems are in place for enrollees to remain in the location of their choice
- Assist members in accessing community resources, including housing, transportation, food assistance, and social services.
- Educate members about their benefits and available services under both Medicare and Medicaid.
- Provide education to members and their families about managing chronic conditions, medication adherence, and preventive care.
- Promote healthy lifestyle choices and self-management strategies.
- Assist enrollees in preventative health strategies, including gap closure
- Follow up with members after hospitalizations or significant health events to ensure continuity of care and prevent readmissions.
- Work closely with primary care physicians, specialists, and other healthcare providers to coordinate care and share relevant information.
- Coordinate with community-based organizations, other stakeholders/entities, state agencies, and other service providers to ensure coordination and avoid duplication of services.
- Advocate for the needs and preferences of enrollees within the healthcare system.
- Evaluate member satisfaction through open communication and monitoring of concerns or issues
- Regular travel to conduct member, provider and community-based visits as required
- Report abuse, neglect, or exploitation of older adults and adult