RN Clinical Care Manager-Sign on bonus -NO weekends/eves/on-call
Bay Cove Human Services, Inc.

Job Info

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Summary:

The Clinical Care Manager (CCM) provides intensive care coordination and clinical care management for MassHealth Members with complex medical and behavioral health needs who are enrolled in an Accountable Care Organization (ACO) or Managed Care Organization (MCO) plan. The CCM collaborates with their respective Community Partner team and the clinical staff of each Enrollee's ACO/MCO's plan to minimize duplicative efforts, promote integrated care, ensure quality and continuity of care, and support the values of person centered planning, Community First and SAMHSA Recovery Principles. The CCM is at the helm of organizing and coordinating resources and services in response to the Enrollee's healthcare needs across multiple settings, and inclusive of both LTSS and Social Determinants of Health (SDH) needs. This role drives outreach and engagement, assessment and care planning, care transitions, health and wellness coaching, as well as community and social services connections in partnership with Enrollees and their care teams.

Job Duties and Responsibilities:

The essential job duties/responsibilities of the position include but are not limited to the information listed below:

• Outreach to and engage enrollees enrolled in ACO and referred for CP program;
• Conduct comprehensive assessment of enrollees including the medical, psychiatric and social issues of enrollees served;
• Review/sign off on medical component of comp assessment of Care Team enrollees;
• Organize and facilitate the effective functioning of the Interdisciplinary Care Team (ICT), including coordinating meetings, facilitating communication and documentation;
• Monitor the enrollee's health status and needs and provide nursing and medical care coordination, including revising health related treatment goals and plans in collaboration with the enrollee and the team;
• Coordinate the development, implementation, monitoring and review of the enrollee care plans, including health care strategies;
• Collaborate closely with PCP and other Providers including, but not limited to community resources, and assure appropriate referrals based on level of care needed to optimize outcomes and minimize risk;
• Collaborate with ACO Plan, PCP and other health care Providers regarding changes in services, care transitions, crisis intervention; while focusing on continuity and quality of enrollee care and potential efficiencies and cost-savings;
• Conduct medication reviews and reconciliation including adjustment by protocol;
• Communicate and collaborate with ACO teams and serve as a team resource;
• Follow up of an enrollee's admission to a planned or unplanned medical or psychiatric inpatient stay, (including hospital, Rehab facility, shelter, substance abuse programs), and collaborate with enrollee, care team staff, ICT and hospital staff to coordinate safe inpatient discharges;

Knowledge and Skills:

• Commitment to the right and ability of people served to live, work, have meaningful relationships and receive resources and supports needed in their community of choice
• Knowledge of person-centered and strengths-based principles and modalities
• Knowledge of clinical and psychiatric rehabilitation values, principles and techniques
• Knowledge of health risks of psychiatric disability
• Knowledge of health promotion and medical care coordination techniques
• Knowledge of motivational interviewing, stage of change and harm reduction techniques
• Knowledge of trauma-informed and culturally competent services
• Sensitivity to the cultural, religious, ethnic, disability and gender issues
• Skills and competence to establish supportive trusting relationships with enrollees
• Knowledge of empowerment and self-advocacy techniques
• Knowledge of available community health and mental health services and resources
• Knowledge of formal and informal assessment practices
• Ability to triage/balance competing priorities
• Ability to make independent judgments and decisions
• Ability to work in a professional and confidential capacity
• Ability to work independently as well as part of a multi-disciplinary team
• Knowledge of personal computer applications and equipment
• Strong organizational and time management skills
• Excellent written and oral communication skills
• Effective relationship management and team building skills

Typical Requirements:

• Minimum of 5 years clinical and case management experienced preferred. Effective skills in managing, teaching, negotiating, and collaborating with multidisciplinary teams and enrollee/family focus. Experience working with people with psychiatric disability, co-occurring disorders preferred. Preference given to bi-lingual/bi-cultural applicants and applicants with lived experience of psychiatric conditions.
• A COVID-19 vaccination is a requirement of the position. One COVID-19 shot is acceptable, contingent on the individual receiving the second shot within the allotted time frame.

Education and Required Credentials/Licenses:

Registered Nurse licensed in the Commonwealth of Massachusetts. RN, BSN or MSN.

Driving Requirements:

Driving is a requirement for this position using a personal vehicle. You must possess and maintain adequate insurance as well as maintain a safe driving record which is subject to annual checks. A valid driver's license must be presented at the time of employment. Applicants must be at least 21 years of age, have maintained a valid US driver's license for at least one year, and must be able to pass a driver's screening background check.

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