Transition of Care Clinical Care Manager
WellSense Health Plan
- Massachusetts New Hampshire
- Permanent
- Full-time
- Full-time remote work
- Competitive salaries
- Excellent benefits
- Completes a targeted general assessment and applicable condition specific assessments.
- Evaluates members’ need for complex care management, disease management or chronic
- Collaboratively develops an individual care plan with the member focusing on the member’s
- Identifies and addresses barriers to optimal self-management and works with the member and
- Assists the member to access all available benefits and resources including family support and
- Utilizes motivational interviewing techniques to engage members in care management and to
- Uses real-time data from electronic medical records, where available.
- Uses BMCHP reporting to access member medical and pharmacy utilization reports, sharing with
- Supports and enhances the member’s capacity to self-manage.
- Evaluates the effectiveness of the care management provided to the member on an on-going
- Utilizes evidence-based practices and guidelines to educate members on specific disease
- Provides or arranges for resources necessary to meet members’ psychosocial and
- Promotes and encourages member collaboration with the primary care provider and other
- Completes documentation in the medical management information system real-time during
- Conducts face-to-face visits with members and providers, community and state agencies, as
- Assists with staff training and mentoring.
- Refers cases to Social Care Management, Behavioral Health Care Management, and Community
- Consults with and refers members to the multidisciplinary team, as appropriate.
- Coordinates member care transitions through pre-admission assessments, post-discharge
- Uses available standardized educational materials in an appropriate reading level to educate
- Monitor members’ labs, tests results, appointments and other data in order to best coordinate
- Maintains HIPPA standards and confidentiality of protected health information.
- Demonstrates strong knowledge of contractual requirements of all BMCHP/Well Sense products
- Participates in after hours on call coverage rotation when requested.
- Adheres to departmental/organizational policies and procedures.
- Other duties as assigned.
- Weekly and on-going from Manager of Care Management
- Bachelor’s degree in nursing or Associate’s degree in Nursing and relevant work experience.
- 3 years related experience in home health care or managed care organization
- 3 years clinical experience with members who have multiple, chronic or complex health
- 2 years experience in care management, care coordination and/or discharge planning
- Experience working with Medicaid recipients and community services
- Experience with FACETS, CCMS, Interqual or other healthcare database
- Pre-employment background check
- Current unrestricted, applicable, state license to practice as a Registered Nurse
- CCM certification preferred
- Regular and reliable transportation and the ability to conduct face-to-face appointments with
- Strong Motivational Interviewing skills
- Strong oral and written communication skills
- Ability to effectively collaborate with health care providers and all members of the
- Strong technical skills and ability to document in the Plan’s care management documentation
- Demonstrated organizational and time management skills
- Able to work in a fast paced environment and multi task
- Experience with Microsoft Office application, particularly MS Outlook and MS Word and other
- Strong analytical and clinical problem solving skills
- Regular and reliable attendance is an essential function of the position.
- Work may be performed in a typical interior/office work environment or in a home office except
- Face-to-face visits may be conducted in a member’s home, shelters, physician practices,
- No or very limited physical effort required. No or very limited exposure to physical risk.