PHS Pediatric Complex Care Manager- HP

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Complex Care Manager works with relevant stakeholders to identify and engage patients in care management with a focus on patient experience, improving health and reducing cost. This position will act as the key medical care manager for pediatric patients with medical and psychosocial complexity. The Complex Care Manager works with relevant stakeholders to engage patients in care management with a focus on patient experience and improving health. Using the information gathered from the family and the medical team, the care manager is responsible for developing and implementing an individualized, patient-centered care plan. Implementation of the care plan may involve: working with partnering organizations to ensure the child is receiving necessary services, assisting families in interactions with school system and community agencies, and acting as a liaison with the child's insurance plan. Excellent interpersonal skills, clinical expertise in pediatrics and the ability to work both independently and collaboratively are key requirements of the job.

This individual will direct and manage Community Health Workers and/or Patient Navigators in completion of assigned patient care related tasks. The individual is responsible for working with patients to identify strengths and barriers and to develop an individualized, patient-centered care plan. Excellent interpersonal skills, clinical expertise in conditions prevalent in the Medicaid population (Substance Use Disorder, Serious Mental Illness, Congestive Heart Failure [CHF, etc.), patient engagement skills and the ability to work independently and collaboratively are key requirements of the job. Nurses or nurse practitioners in the position will work in one of 3 programs: Primary Care-based Complex Care Management, Readmissions Care Team, or ED-based Complex Care Management. Nurses or nurse practitioners in all programs will collaborate closely with one another in the care of shared patients. Nurses or nurse practitioners will be designated to one of three clinical sites depending on the specific program he/she is a part of: Primary Care Practice, Emergency Department (ED), or Inpatient. Details on the 3 Care Management Programs are described below:

• Primary Care-based Complex Care Management: The CCM team will be embedded in local primary care practices. The team will partner closely with PCPs, Integrated Behavioral Health Professionals, Pharmacists, and other local resources in the Primary Care Practice to develop multi-disciplinary care plans. Nurses will proactively seek out opportunities to care for patients, including during PC visits, during ED or IP visits, out in the community, or on the phone. Nurses will be paired with Community Wellness Advocates who will partner with nurses on a shared patient panel, and will focus on social determinants of health.
• Readmissions Care Team (RCT): The Readmissions Care Team is a multidisciplinary team of healthcare professionals that provides comprehensive, wrap-around care for patients during their inpatient stay and immediately after their discharge. The team specifically works with patients who have the greatest risk of readmissions. By complementing existing care teams on the inpatient and outpatient side, the Readmissions Care Team serves a critical role in connecting the dots across care providers and community agencies. The team works at inpatient facilities, and aims to fully integrate with inpatient care operations - documenting in local medical records, participating in care planning efforts, etc. to ensure seamless care planning for patients while also serving as the link to continuing outpatient care. This individual will direct and manage Social Workers and/or Patient Care Coordinators in completion of assigned tasks related to this care plan. Clinical expertise in common high-risk medical conditions (e.g. CHF, diabetes, COPD, etc.), familiarity with home health and community-based resources, as well as excellent interpersonal skills, patient engagement skills and the ability to work independently and collaboratively are key requirements of the job.
• ED-Based Care Management: The ED Care Managers will support high risk patients during and immediately after their ED visits, with a focus on avoiding unnecessary admissions and subsequent ED visits. The ED CM will partner closely with patients' primary care-based Care Management teams to not only address immediate needs as part of the ED visit, but to facilitate connections back to Primary Care. Clinical expertise in common high-risk medical conditions (e.g. CHF, diabetes, COPD, etc.), familiarity with home health and community-based resources, as well as excellent interpersonal skills, patient engagement skills and the ability to work independently and collaboratively are key requirements of the job.

Our Investment in You:

* Hybrid work environment

* Competitive salaries

* Excellent benefits

Key Functions/Responsibilities:

* Supports programs and clinical best practices with the objective of improving health outcomes, preventing hospital readmissions, improving member safety and reducing medical errors, and promoting health and wellness activities, where appropriate.

* S/he will also work with partnering organizations to make sure that children have all needed medical services

* Collaboration with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning.

* Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leaders

* The individual is responsible for working with patients to identify strengths and barriers and to develop an individualized, patient-centered care plan. Excellent interpersonal skills, clinical expertise in pediatrics and the ability to work both independently and collaboratively are key requirements of the job

* Educate the patient and their caregivers on their conditions and medications, and build their self-management skills;

* Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.

* Facilitates interdisciplinary consultation on patient's behalf through participation in clinical review team (CRT) meetings

* The individual will arrange for case conferences as needed, involving school, day care and early intervention services providers as appropriate.

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  • Ability to execute core care management duties:
  
  
  
  

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    • Comprehensive assessment: bio-psycho-social-spiritual
    • Collaboration with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning (HCP, MOLST)
    • Implementation of care plan;
    • Collaboration with community partners, such as VNA agencies, caregiver programs (PCA, ADH, and AFC), DME providers and social service agencies; 5) assessment of goal completion, with transition of patient to inactive or graduated status as appropriate.
    
    
    
    
  
  
  
  

* Uses reflective, empathetic language and open-ended questions to understand what the patient truly wants for him/herself beyond being healthy and staying out of the hospital

* Meet the patient where he/she is; observe the patient without intervention or judgment

* Has knowledge of common chronic medical conditions presented in the population served and is able to:

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    • Educate the patient on their medication conditions and medications, and build their self-management skills;
    • 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.
    
    
    
    
  
  
  
  

* Delegates assignments to Community Health Workers and/or Patient Navigators or Social Workers and follows up on completion. Manages staff performance through the following:

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    • Tracks individual performance metrics
    • Provides one-on-one supervision to each team member on a regular basis
    • Consistently available for timely consult regarding patient matters during business hours
    • Develops on-boarding curriculum in collaboration with Medical Director
    • Facilitates access to appropriate training and educational resources
    • Facilitates access to appropriate supportive and psychosocial resources
    • First point of contact for corrective/disciplinary matters as needed.
    
    
    
    
  
  
  
  

* Meets regularly with leaders at the local clinical site (Primary Care, ED, inpatient), and care management supervisor, to triage program issues appropriately.

* Participates in local site operations, including team meetings, curbsides with care team members, etc.

* Actively participates in planning and growth of program with relevant stakeholders as needed, to respond to evolving needs of MassHealth ACO.

* Facilitates interdisciplinary consultation on patient's behalf through participation in rounds, team meetings and clinical reviews

* Complies with established metrics for performance and adheres to documentation and work flow standards

* Maintains HIPAA standards and confidentiality of protected health information.

* Adheres to departmental/organizational policies and procedures.

* Care Manager will work full-time at the clinical site of care

* Metrics:

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    • ED and inpatient visits
    • Total medical expense
    • Patient satisfaction
    • Clinical outcomes
    • Provider satisfaction
    • Avoidable admissions
    
    
    
    
  
  
  
  

* Other duties as assigned

Supervision Exercised:

* None

Supervision Received:

* General guidance

Qualifications:

* Ability to travel to North Shore MA / Middlesex / Essex Counties

* Independent transportation

Education Required:

* BS in Nursing

Education Preferred:

* Masters in Nursing

Experience Required:

* A minimum of 2-5 years of pediatric clinical experience is preferred.

* Direct care experience in a pediatric outpatient, community or multidisciplinary setting preferred.

* Preferred experience:

* Experience working with vulnerable patient populations

* Home care or clinic

* Motivational interviewing

* Clinical experience working with patients with multiple complex needs

* Ability to adapt to changes in healthcare delivery at local and systems level

* Extensive knowledge of healthcare systems and community resources

* Ability to leverage systems and resources for improved patient outcomes

* Strong organizational and time management skills

Experience Preferred/Desirable:

* Experience working with vulnerable patient populations

* Home care or clinic

* Motivational interviewing

* Clinical experience working with patients with multiple complex health issues

* Care management

Required Licensure, Certification or Conditions of Employment:

* Successful completion of pre-employment background check

* Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts. AND/OR Completed an accredited educational program for Nurse Practitioners

* Transportation

Competencies, Skills, and Attributes:

* Manage projects

* Detail oriented, excellent proof reading and editing skills.

* Excellent interpersonal skills and ability to work collaboratively

* Self-management skills, including ability to prioritize and set patient-centered goals

* Excellent written and verbal communication

* Able to maintain professional boundaries

* Ability to work with diverse, safety-net population

* Skilled at engaging difficult to engage patients-build rapport, trust

* Creative problem solver

* Ability to adapt to changes in healthcare delivery at local and systems level

* Extensive knowledge of healthcare systems and community resources

* Ability to leverage systems and resources for improved patient outcomes

* Strong organizational and time management skills

Working Conditions and Physical Effort:

* Ability to work outside of normal business hours as needed.

* Regular and reliable attendance is an essential function of the position.

* Work is normally performed in a typical remote home office work environment.

* No or very limited physical effort required. No or very limited exposure to physical risk.

Compensation Range

$88,500 - $128,000

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Note: This range is based on Boston-area data, and is subject to modification based on geographic location.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees