Senior Care Options Transition RN

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier. We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

The Care Manager - Nursing (RN CM) will ensure that all members receive timely care management (CM) across the continuum, including transitions of care, care coordination and navigation, complex case management, population health and wellness interventions, and disease/chronic condition management per department guidelines. The nurse care manager possesses strong clinical knowledge, critical thinking skills, and ability to facilitate a care plan which ensures quality medical care for the member. The RN CM works closely with the member, the caregiver/authorized representative, and providers to meet the targeted member-specific goals. Based on national standards for CM practice, the RN CM focuses on empowering the member to support optimal wellness and improved self-management.

Administer assessments, collaborate with the member/caregiver and providers to develop a plan of care, implement member-specific CM interventions, and evaluate plan of care and revise as needed. Facilitate program enrollment utilizing key motivational interviewing skills Provide targeted health education, proactive strategies for condition management, and communication with key providers and vendors actively involved in the member’s care Perform both telephonic and face to face outreach to assess barriers to wellness, medical, behavioral, and psychosocial needs of the member. Collaborate with member/caregiver and the facility care team to coordinate a safe transition to the next level of care, which includes but is not limited to ensure understanding post-hospital discharge instructions, facilitate needed services and follow-up, and implement strategies to prevent re-admission Performs case documentation in applicable CM system according to department and regulatory standards Collaborates and liaises with the interdisciplinary care team, to improve member outcomes (i.e., Utilization Management, Medical Director, pharmacy, community health workers, dementia care specialists, wellness, and BH CM) Attend and present (as appropriate), high risk members at interdisciplinary rounds forum Maintain professional growth and development through self-directed learning activities Other duties and projects as assigned.