iCMP RN Care Manager, Westwood/Medford - Hybrid
Mass General Brigham Community Physicians

About Us

Mass General Brigham Community Physicians (formerly known as Partners Community Physicians Organization) is a member of the Mass General Brigham system, founded by Brigham and Women's Hospital and Massachusetts General Hospital. Our doctors are part of a broad network of providers that includes our world-renowned academic medical centers, nationally recognized specialists, conveniently located community hospitals, exceptional rehabilitation and home care services, and more!

Our continued dedication to clinical excellence, focus on diversity, equity, and inclusion, and generous employee offerings, such as our competitive benefits package, allow our professionals to build an exciting career as we all work together to positively impact the health of our patients. Bring your talent to MGB Community Physicians and find out just how far it can take you! Are you ready to join our team?

The Opportunity

We are seeking a full-time, 40-hour RN Care Manager to support iCMP (Integrated Care Management) at two of our practices:

• Medford (137 Main Street) - Internal Medicine
• Westwood (90 Brigham Way) - Primary Care

As a hybrid opportunity, the position entails onsite coverage 2 days per week on site (days can be flexible dependent on candidate's schedule) and remote coverage 3 day per week. The operating hours are Monday through Friday from 8:00am to 5:00pm (shifts are staggered). Remote coverage include traveling to patient homes.

The iCMP RN Care Manager is responsible for establishing, implementing, monitoring, and evaluating high-quality, cost-effective care plans for a designated group of patients in the ambulatory setting. The individual will need sound clinical judgment, effective problem-solving skills, critical thinking, excellent organizational and interpersonal skills, experience with team-based care, and the ability to multitask. A broad-based knowledge of available health services across the continuum, insurance benefit design and reimbursement methods, and experience in acute or community case management will be needed to be successful.

Responsibilities

• Manages all transitions of care for MGB CP patients from inpatient to outpatient/home as applicable.
• Conducts engagement, outreach and education activities for patients identified as requiring care coordination services.
• Routinely consults with the patient's PCP (Primary Care Physician), specialist physicians as well as other members of the care team regarding high priority patients and the patient centered plans of care.
• Initiates telephonic contact with eligible patients to conduct an initial assessment, patient/family health education, and develop a patient centered plan of care.
• Demonstrates excellent interpersonal skills when communicating with patients, families, and physicians to develop rapport, build trust, and engage patients in health promotion activities.
• Serves as a key resource to assigned patients, helping to proactively address their questions, concerns, and care needs by guiding and facilitating access to providers and services.
• Influences appropriate utilization of health care resources by coordinating patient care, encouraging involvement in disease and case management programs.
• Communicates with other health care clinicians throughout the continuum regarding patient's care needs, utilization plan and applicable follow up plans.
• Establishes a consistent schedule of communication and reporting with involved providers and the patient with intended goal of reviewing patient status and progress toward goals.
• Collaborates with and seeks feedback from the program primary care physician, care coordination management and/or medical director regarding challenging patient situations.
• Conducts case reviews at practice and /or care management meetings.
• Utilizes electronic medical record systems to document, monitor, and evaluate patient interventions and care plans.
• Keeps current with related trends in ambulatory care management including topics related to health education and coaching.
• Commitment to coaching (rather than teaching) patients to improve their health behavior to attain their health- related goals.

Qualifications
Qualifications

• Active RN license to practice in Massachusetts required, BSN preferred.
• Minimum of 5 years of experience in a hospital, health plan or community practice case management role required.
• Certification in case management (CCM) or other applicable professional certification preferred.
• Previous experience working in an ambulatory setting such as a health center or physician's office is preferred.

EEO Statement
Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.

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