JOB DESCRIPTION
Position: Complex Care Manager
Department: Pediatrics/Population Health
Schedule: Full Time
Special Kids, Special Care Program- Covering Greater Boston Area and Central MA.
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. This role will be part of an interdisciplinary team serving culturally diverse families with chronic illnesses, special needs, and a variety of neurodevelopmental and related diagnoses. The individual is responsible for outreach to families, meeting with families during clinic sessions, and making home visits in the community. 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.
Key Functions/Responsibilities:
- Ability to execute core care management duties:
- 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.
- Collaboration with program stakeholders and community partners.
- Coordinates with health care providers to make sure needs are being met.
- S/he will also work with partnering organizations to make sure that children have all needed medical services
- 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
- Has knowledge of common chronic medical conditions presented in the population served and is able to:
- Educate the patient and their caregivers on their 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.
- Meets regularly with team members and care management supervisor to triage program issues appropriately.
- Actively participates in planning and growth of program with relevant stakeholders as needed
- 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.
- Complies with established metrics for performance and adheres to documentation and work flow standards
- Maintains HIPAA standards and confidentiality of protected health information.
- Follows established infection control and safety procedures.
- Adheres to departmental/organizational policies and procedures.
- Care Manager will work full-time from their home and visit patients in the community
- Other duties as assigned
Must adhere to all of BMC’s RESPECT behavioral standards.
(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).
About the ideal candidate:
- MS in nursing
- Certification as a Pediatric or Family Nurse Practitioner
- Massachusetts NP license
- Minimum of 3-5 years direct clinical experience required. Direct care experience in a Pediatric outpatient and multidisciplinary setting helpful, but not required.
- Must be self-directed, a self-starter, and able to implement new programs.
- Bilingual is a plus
- Direct care experience in a Pediatric outpatient and multidisciplinary setting helpful is a plus
- Perform other duties as assigned or as needed.
- Follow established infection control and safety procedures.
- Conforms to standards of performance and conduct, including those pertaining to patient rights, so that the best possible customer service and patient care may be provided.
- Oversee transitions in care, particularly from hospital to home. To this end, s/he will maintain close contact with the attending physician and senior resident on the inpatient unit during any periods of hospitalization, consult with the Complex Care Pediatrician as appropriate; collaborate with the discharge nurse on post-acute care plans; and ensure a smooth transition from inpatient care back to the child’s pediatrician and the larger community.
- S/he will arrange for case conferences as needed, involving the child’s school or day care and early intervention services providers as appropriate.
- The Nurse will contact the family at least once every six months to monitor the child’s status, review family concerns, and assess the appropriateness of service utilization. S/he will also alert the child’s pediatrician and the Complex Care Pediatrician via secure email to any important new clinical information on the child and also note this information in the EMR and on the care plan.