RN Care Manager - Pease & South Berwick

Wentworth-Douglass Hospital, an affiliate of Mass General Brigham, is committed to supporting patient care, research, teaching, and service to the community.  We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve. At Mass General Brigham, we believe in equal access to quality care, employment and advancement opportunities encompassing the full spectrum of human diversity: race, gender, sexual orientation, ability, religion, ethnicity, national origin and all the other forms of human presence and expression that make us better able to provide innovative and cutting-edge healthcare and research.

In cooperation with the health care team, manages all aspects of patient-centered care for a panel of chronically ill and/or high utilizing patients in a primary care medical practice. The nurse directly interfaces with physicians, healthcare teams, patients and their unpaid caregivers in managing care. Care Managers shall access and review the records of patients identified as increased risk by various reports and other means in order to assure treatment plans are optimized to mitigate such risks.

1. Performs comprehensive case management and care coordination for a defined panel of chronically ill/high utilizing patients using the chronic care model.
a. Completes a comprehensive health assessment for each patient in the panel.
b. Develops and communicates (with patient, caregiver and primary care Provider / health care team) a comprehensive, individualized care plan based on evidence based best practices and patient preferences. Places care plan within EMR for review by other care team members.
c. Provides pro-active patient management and telephonic follow-up (according to the care plan).
d. Manages and coordinates transitions of care by communicating the care plan to other providers and ensuring that timely clinical data is available for treatment decisions in other settings as needed. (Hospital, home care, SNF, specialists, etc).
e. Incorporates the principles of self-management and shared decision making in all aspects of patient care.
f. Provides direct caregiver support.
g. Facilitates patient and caregiver access to community resources relevant to the patients' needs, including referrals to transportation programs, Meals on Wheels, etc.
h. Assists in the identification of eligible patients for the program and initiates contact to describe the program and answer questions.
i. Maintains all documentation according to standards and requirements.
j. Provides patient teaching on diabetes management, including starting and using insulin therapy, proper use of peak flow meters and inhalers, monitoring of weight and diet for patients with CHF.

2. Demonstrates effective teamwork and collaboration with the primary care provider and the care team.
. Engages the patient and caregiver as active members of the care team and utilizes shared decision making in developing and executing the care plan.
a. Demonstrates leadership skills in organizing the care team around the needs and expectations of patients.
b. Initiates and participates in regular meetings with the providers and the care team to review patients' status and modify the care plan. Documents the care plan based on needs identified by the involved disciplines, the patient, and/or patient's representative(s).
c. Communicates pertinent changes in each patient's status to all care team members.
d. Works effectively with the provider and care team to solve problems.
e. Communicates with other WDH departments and sites to foster collaboration as a `system' around the patients served.
f. Collaborates with other WDH Chronic Disease Care Managers to develop standards and improvements for the program.
g. Engages and participates in regular meetings/calls with insurance companies/payers to discuss care management opportunities for patients if applicable.

3. Collects data pertinent to the program and prepares reports as needed
. Collects data electronically or manually to support the activities of the program.
a. Assists in the development, data collection, and reporting of quality metrics in support of the program.

Experience Minimum Required
• Three years of nursing experience as a Registered Nurse in an inpatient or outpatient setting.
• Minimum 180 patient case load.
• Strong clinical assessment and patient education and health coaching skills and knowledge of medical standards of care.
• Proficient clinical nursing skills (medication administration, venipuncture, wound care)
• Excellent interpersonal skills.
• Demonstrated ability to work independently and as a member of a multi-disciplinary team.
• Proficient in computer use, the Internet, and health information technology.

Education Minimum Required
• Active RN License Bachelor's degree in nursing or equivalent experience.

Special Skills Minimum Required
• The ideal candidate will possess excellent interpersonal and clinical nursing skills, with a flexible and creative approach to problem solving along with the ability to motivate patients living with chronic illness to engage in positive health behaviors, set realistic goals and optimize their level wellness.
• The candidate will have a demonstrated ability of working effectively as a member of an interdisciplinary team, displaying good clinical judgment and decision-making skills.
• Central to the role of the Nurse Care Manager in the Primary Care medical office is a commitment to "coaching" (rather than "teaching") patients to improve their health behaviors to attain their health-related goals.
• An ability to work independently is essential.
• Special Skills Preferred/Desired
• Certification in Chronic Care Management is preferred.

Licensure and/or Certifications Required
• Registered Nurse (NH)

Wentworth-Douglass Hospital 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.