Completes clinical assessments on each member to determine the educational health needs based on their disease process, and to monitor their level of adherence. Provides and promotes self-management support including care integration for members enrolled in the population based program. Leads the interdisciplinary team in the development and implementation of the care plan to enhance the members overall health, and to achieve appropriate utilization. Assesses plans, implements, coordinates, monitors and evaluates care plans, services and outcomes to maximize the health of members.
- Completes a comprehensive assessment and develops a care plan utilizing clinical expertise to evaluate the member’s needs for alternative services. Assesses short-term and long-term needs and establishes condition management objectives
- Provides ongoing telephonic outreach to conduct ongoing focused assessments
- Educates and assists members in understanding their disease process in an effort to self management and maximize optimal health
- Emphasizes the importance of health education and teaches member behavior modification techniques
- Utilizes evidenced based guidelines to educate members on their specific disease processes
- Identifies member educational needs and mail appropriate educational material to each member
- Assess/Monitor members clinical and behavior modification changes and document in CCMS
- Promotes and encourages members regarding adherence to their care plan as prescribed by and in collaboration with their treating physician
- Communicates/Collaborates with provider regarding member needs.
- Acts as a liaison and member advocate between the member and their family, physician, and facilities/agencies.
- Facilitates interdisciplinary teamwork to ensure coordination of care through participation in rounds, team meetings and clinical reviews in CCMScdocuments clinical assessments and coordinator of care in the medial management information system in a timely manner that meets regularity and accreditation standards as well as internal policy.
- Utilizes data to ensure that clinical interventions result in improved clinical outcomes and appropriate utilization of services at an appropriate cost.
- Assess options for care including use of benefits and community resources to update the care plan as needed.
- Triages cases to CM select as appropriate
- Communicates with Physicians, Hospitals, Ancillary providers and Community agencies as needed to communicate or receive essential clinical and or psychosocial information related to a members care.
- Maintains Hippa standards and confidentiality of protected health information. Reports critical incidents and information regarding quality of care issues.
- Ensures compliance with all state and federal regulations in day to day activities
- Other duties as assigned
- Bachelors Degree in Nursing or Nursing School Degree with equivalent relevant work experience.
- Certification in disease-management related areas such as Chronic Care Professional (CCP)by Health Sciences Institute, Certified Health Coach (CHC) by National Society of Health Coaches; or a patient education body such as Certified Diabetes Educator (CDE) by National certified Board for Diabetes Educators or Certified Asthma Educator (AE-C)by National Asthma Educator preferred.
- CCM certification.
- 3 years related experience in a health insurance environment working in Disease Management
- 2 years experience in care coordination, home care and or discharge planning.
- Experience in a health plan or insurance environment
- Experience in a Disease Management Vendor organization
Certification or Conditions of Employment:
- Current MA or NH state licensure as a Registered Nurse
Competencies, Skills, and Attributes:
- Effective collaborative and proven process improvement skills.
- Strong oral and written communication skills; ability to interact within all levels of the organization.
- A strong working knowledge of Microsoft Office products.
- Demonstrated ability to successfully plan, organize and manage projects
- Detail oriented, excellent proof reading and editing skills.
Working Conditions and Physical Effort:
- Regular and reliable attendance is an essential function of the position.
- Work is normally performed in a typical interior/office work environment.
- No or very limited physical effort required. No or very limited exposure to physical risk.
- Fast paced office environment
- Travel required up to 50% of the time
Boston Medical Center HealthNet Plan - 23 months ago