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Job Summary

Under the administrative direction of the Clinical Manager, the Nurse Case Manager (NCM) for Tufts Medicare Preferred (TMP) 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 NCM is responsible to manage all aspects of member care during assigned assessments, while working within a healthcare team. The NCM directly interfaces with physicians, other members of the primary care team, members, and their caregivers in identifying risk factors, conducting assessments, and developing and implementing care plans to comprehensively manage their members' care.

Job Description

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.

KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS* (in order of importance)
% of TIME
(Optional)
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.

JOB QUALIFICATIONS: KNOWLEDGE/SKILLS/ABILITIES

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.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel,
Overtime)
* Fast paced office & onsite environments that require the balancing of multiple demands.
* Ability to carry supplies and or standard lap top computer with estimated weight of 15-30 pounds
* Certain tests and immunizations may be required, depending on the specific requirements of the network facility to which the onsite Transition manager may be assigned.
* Occasional evening, early morning or weekend work may be required.
* A valid driver's license and access to an automobile for travel is required.
* Travel to Tufts HP office locations is required for meetings, conferences or educational classes
* Travel requirement may change appreciably based on corporate business needs.

CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.

*Essential functions occur simultaneously, therefore, the employee must be able to appropriately handle each essential function, prioritize them and seek assistance when necessary. These functions need to be performed on a consistent and regular basis, using good judgment. Ability to learn and apply company policies consistently, seeking out guidance when necessary, is required.

THIS DESCRIPTION IS NOT INTENDED TO BE A COMPLETE STATEMENT OF JOB CONTENT; RATHER IT ACTS AS A GUIDE TO THE ESSENTIAL FUNCTIONS PERFORMED. MANAGEMENT RETAINS THE DISCRETION TO ADD TO OR CHANGE THE DUTIES OF THE POSITION AT ANY TIME.

Tufts Health Plan is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. For our EEO Policy Statement, please click here. If you d like more information on your EEO rights under the law, please click here.