Req#: R34749
Category(s): Nursing, License Practical Nurse
Full Time / Part Time: Full-Time
Shift: First

LPN Care Manager, ACO Transitions of Care Nurse is responsible for the management of care for a defined group of patients including complex care management, transitions of care, as well as coordination of care. Major responsibilities include accurately identifying patients for care management, developing individualized plans of care, assessing/addressing barriers to care, medication reconciliation, medication titration as well as ensuring adherence to quality measures. The goal is to work with patients to optimize control of chronic medical and mental health conditions, improve functional status, reinforce self-management plan, and prevent/minimize long-term complications as well as to avoid unnecessary emergency room visits or hospital admissions. They will work collaboratively with physicians and other health team members along the patient’s continuum of care and are available to patients and families for care coordination/education through face-to-face visits, home visits, if necessary, as well as telephonic interactions. In addition, they will assist with advance directives, palliative care, hospice, and other end-of-life care coordination. Appropriate documentation in patient medical records and/or care management application is required and is vital.
Assumes accountability for own professional practice and for aspects of patient care delegated to others. Practices within the ethical and legal parameters of nursing practice. This description covers the essential functions of the position. Incumbent is expected to perform other similar and related duties as assigned.

Job Responsibilities: 

Coordinates, oversees, and directs the interdisciplinary team members to provide care that is safe, timely, effective, efficient, equitable, and client-centered to the assigned patient population. Responsible for appropriately identifying patients for care management utilizing multiple sources including physician referrals, referrals from transitions of care, health plans as well as complex lists of patients from the ACO. Conducts whole person assessments to determine individual patient needs and create individualized self-management plans of care in conjunction with the patient/family. Evaluate the effectiveness of the plan of care and revise as necessary to meet goals. Assists patients to make informed decisions about their care by acting as their advocate regarding their clinical status and treatment options. Promotes quality and cost-effective interventions and outcomes to patients in collaboration with the primary care providers and/or specialists. Manages transitions of care for patients discharged from the hospital, behavioral health facility/program, emergency room, or from a skilled nursing facility. Responsible to review the discharge summaries, follow up on testing that is pending, ensure ordered services are in place. Outreaching to the patients to perform a medication reconciliation, ensure patients understanding of discharge instructions and assess for further care management needs. Providing disease management/complex care management to patients face to face or telephonically as well as utilizing technology that becomes available. Providing home visits to patients when appropriate. Titrating medications via protocols when necessary. Overseeing Care Coordinators and Community Health Workers which includes addressing quality indicators that are out of range and assisting patients to reach targets. Accountable for remaining current with knowledge of care management, availability of community resources and quality improvement methodologies Appropriate documentation in patient medical records and/or care management application is required and is vital. Care management program metrics including, emergency room utilization, and hospital admission/readmission data will be reviewed on a regular basis. Develops and collects data to identify trends in utilization of health care resources. Assumes accountability for own professional practice and for aspects of patient care delegated to others. Practices within the ethical and legal parameters of nursing practice.

Required Work Experience: 

Massachusetts LPN License, Driver’s License and BLS CPR Minimum of 4 years of experience 2 years Care Management or Transitions of Care experience strongly preferred.  Strong communication, interpersonal and problem-solving skills to advocate for optimal patient outcomes.  Capacity to work closely with patients, physicians and their office staffs and managed care plans.  Strong organizational and prioritization skills.  Attention to detail and able to perform work independently.  Excellent verbal and written communication and interpersonal skills. Bilingual skills preferred

​SCHEDULE:

No weekends and No Holidays Full Time 40 hours Location – 280 Chestnut Street – Department home office – will also entail meeting with patients at the hospital & home visits as needed

THE ADVANTAGES OF WORKING WITH BAYSTATE!

Excellent Compensation High-quality, low-cost medical, dental and vision insurance Pet, home, auto and personal insurance 403b retirement company match & annual company contribution increase based on years of service Life insurance Reimbursement for a variety of wellbeing activities, included but limited to: gym membership and equipment, personal trainer, massage and so much more!

Under the direction of the RN Care Manager, the LPN Care Manager is responsible for the management of care for a defined group of ACO BeHealthy patients (TOC team, Primary Care, CHCs, etc.), including enhanced care management, baseline care coordination, and transitions of care.  Major responsibilities include accurately identifying patients for care management, developing individualized plans of care, assessing/addressing barriers to care, medication review, education of medical needs, communication to providers, and ensuring adherence to quality measures. Working as part of TOC team includes daily rounding on ACO BeHealthy patients admitted in area BH hospitals. The goal is for patients to optimize control of chronic medical and behavioral health conditions, improve functional status, reinforce self-management plans, and prevent/minimize long-term complications as well as avoid unnecessary emergency room or hospital admissions. The LPN will work collaboratively with RNs, physicians, and other health team members along the patient's continuum of care and are available to patients and families for care coordination/education through face-to-face visits, telephonic interactions, as well as home/community visits as needed. Appropriate documentation in patient medical records and/or care management applications is required. Participates in team meetings and other departmental meetings as needed. 

Assumes accountability for own professional practice and for aspects of patient care delegated to others.  Practices within the ethical and legal parameters of the Massachusetts Board of Registration.  This description covers the essential functions of the position.  The incumbent is expected to perform other similar and related duties as assigned.

Job Requirements:

1) With RN oversight, coordinates, oversees, and directs the interdisciplinary team members to provide care that is safe, timely, effective, efficient, equitable, and client-centered to the assigned patient population.

2) Responsible for appropriately identifying patients for care management utilizing multiple sources, including physician referrals, referrals from transitions of care, health plans as well as complex lists of patients from the ACO.

3) With RN oversight, conducts whole-person assessments to determine individual patient needs and create individualized self-management plans of care in conjunction with the patient/family.  Evaluate the effectiveness of the plan of care and revise it as necessary to meet goals.RN to provide a final review of the assessment.

4) Exceptional assessment and clinical skills needed, flexibility to work needs, and ability to adapt to fast-paced environments, as well as ability to care for complex and diverse patient populations within the ACO.

5) Promotes quality and cost-effective interventions and outcomes to patients in collaboration with the primary care providers and/or specialists.

6) Manages transitions of care for patients discharged from the hospital, behavioral heatlth facility/program, emergency room, or from a skilled nursing facility.  Responsible to review the discharge summaries, follow up on testing that is pending, ensure ordered services are in place.  Outreaching to the patients to perform a medication review, ensure patients understanding of discharge instructions and assess for further care management needs.

7) Providing disease management/education to patients face to face or telephonically as well as providing home and/or community visits as appropriate.

8) Exceptional organizational skills, ability to multi-task, and work well as a team.  Collaborate and seek guidance from the RN or manager as necessary.

9) Accountable for remaining current with knowledge of care management, availability of community resources, and quality improvement methodologies

10) Appropriate documentation in patient medical records and/or care management applications is required and is vital.  Monitor care management program metrics including, ACO enrollment volumes, transitional outreach post ED/hospital use, emergency room utilization, and hospital admission/readmission data.

11) In collaboration with the RN and teams, develops and collects data to identify trends in untilization of health care resources.

12) Assumes accountability for own professional practice and for aspects of patient care delegated to them or others.

13) Practices within the ethical and legal parameters of nursing practice.

14) Provide culturally competent care to a wide range of diverse patients, taking into account the physiological, developmental, and psychosocial needs of patients 0-64 years old.

15) Assists patients in making informed decisions about their care by acting as their advocate regarding their clinical status and treatment options

Minimally Required Education:

Completion LPN accredited nursing program

Preferred Education:

n/a

Minimally Required Experience:

2+ years in a clinical setting working as LPN. Current driver's license with available transportation.

Preferred Experience:

1) Experience community/health center-based nursing skills preferred.

2) Bilingual skills applicable to the patient population preferred. 

Skills/Competencies:

Strong communication, interpersonal, and problem-solving skills to advocate for optimal patient outcomes.  Capacity to work closely with patients, physicians, and office staff to coordinate a plan of care. Strong organizational and prioritization skills.  Attention to detail and ability to perform work independently. Outlook, Microsoft Word, Microsoft Excel, basic computer skills required.

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.

DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.

Education:

Non-Graduate

Certifications:

Basic Life Support – Other, Licensed Practical Nurse – Other

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

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