Care Manager at Tufts Health Plan in Watertown, Massachusetts

Job Description:

We enjoy the important work we do every day on behalf of our members.

Job Summary

Under administrative and clinical direction from the Care Management Team Leader, the Care Manager (CM) provides timely and clinically appropriate case management interventions to a geriatric population based on nationally recognized standards of case management practice and geriatric expertise. The CM will develop effective working relationships with members, families and providers in order to actively participate in the assessment of the member's needs and the development of individualized care plans, match the available health plan benefits and community services to those needs, coordinate the ongoing evaluation of the care plan, recommend and facilitate adjustments to the care plan and services in place, and focus on optimizing the member/family's level of independence in navigating the healthcare system at all levels of the continuum.
This role is the corner stone of assuring the most appropriate services and resources are provided for our members. Experience in working with the elderly in the community and coordinating care is a plus, as well as experience and comfort with difficult life issues including end-of-life.

Job Description

• The Care Manager Assesses member's health care needs in order to collaborate with the member, their family and providers to develop a quality and cost effective plan of care to improve, maintain or support optimal wellness within the context of the member's illness, medical condition and plan benefits.




• Refers member to consultant, Dementia, Pharmacy, Social Services or Palliative Care/Hospice as needed.




• Demonstrates accountability for member panel including assessing and documenting within department standard timeframes, coordinating care with the medical providers, participating in medical group meetings as required, doing root cause analysis on request for cases with readmissions.




• Participates in department staff meetings or other on-site meetings as requested or required.




• Identifies documents and refers potential QA occurrences to the Clinical Quality Department for review.




• The Care Manager provides support, coaching and self-managed skills for member to assist member/caregiver in understanding disease and symptom management. Advocates for the member's care and informational needs to support member/family independence and enable them to make informed health care decisions.




• The Care Manager integrates utilization management knowledge and Case Management department policies and procedures within prospective, concurrent and retrospective case review activities to ensure effective utilization of resources and achievement of clinical and financial goals. Participates in Team quality improvement projects by identifying opportunities to enhance present workflows/policies and presenting information to support a potential outcome improvement.

Requirements

EDUCATION: (Minimum education & certifications required)

* Bachelors of Science degree is strongly preferred,

* Registered Nurse with current unrestricted Massachusetts state license

* CCM highly desirable

EXPERIENCE: (Years of experience)

* Minimum of five years of clinical nursing experience.

* Experience in medical case management highly desirable

* Experience in extended care planning highly desirable (discharge planning to Rehab, SNF, home care, hospice)

* Proficiency in a second language is desirable

SKILL REQUIREMENTS: (Include interpersonal skills)

Skill in conducting a comprehensive clinical and social geriatric assessment

Skill in incorporating proven assessment, coaching techniques such as motivational interviewing, to promote health education to strengthen member/caregiver motivation and commitment to change behaviors to support health and wellness.

Ability to develop a comprehensive member centric care plan in collaboration with member and care giver to ensure optimum disease/chronic condition management that promotes self manage practices and improves symptom management.

Understanding of geriatric condition management

Understanding of community resource referral process

Understanding of Level of Care and SNF, LTACH/AIR benefits Understanding of member benefits and appeal process

Computer skills are required. Intermediate level understanding of Microsoft Office programs is a must, in addition to being facile in learning multiple other systems and programs and working within them on a daily basis.

What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!

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