Boston Medical Center
Position Summary
The Complex Care Manager works with relevant stakeholders to identify and engage patients in care management with a focus on patient experience, improving health and reducing cost. This individual will direct and manage Community Health Workers and/or Patient Navigators in completion of assigned patient care related tasks. The individual is responsible for working with patients to identify strengths and barriers and to develop an individualized, patient-centered care plan. Excellent interpersonal skills, clinical expertise in conditions prevalent in the Medicaid population (Substance Use Disorder, Serious Mental Illness, Congestive Heart Failure [CHF, etc.), patient engagement skills and the ability to work independently and collaboratively are key requirements of the job.
Schedule and Work Setting This position is Monday – Friday, 40 hours FTE, no weekends or holidays observed by BMC. Business hours are typically between 8:30 am and 5 pm. It is a blended hybrid role with opportunities for both in-person and remote work from home. Candidates must have a working vehicle and be able to travel independently. The role serves patients in the Brockton, Randolph, Raynham, Bridgewater, Easton, and Quincy communities. Approximately 2 days per week are worked from home, ~3 days in the community, practice site, or patient home settings. The dress code is business casual.
Team and Collaboration The CCM team will be embedded in local primary care practices and partners closely with PCPs, Integrated Behavioral Health Professionals, Pharmacists, and other local resources to develop multidisciplinary care plans. Nurses proactively seek opportunities to care for patients, including during PC visits, ED or IP visits, out in the community, or on the phone. Nurses will pair with Community Wellness Advocates who focus on social determinants of health.
Compensation Compensation will be based on a salary/incentive plan.
Essential Responsibilities & Duties
Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leaders.
Execute core care management duties, including:
Comprehensive assessment: bio‑psycho‑social‑spiritual.
Collaboration with patient and care team to develop patient-centered care plan, focusing on chronic disease management, social determinants, transitions of care and advanced care planning (HCP, MOLST).
Implementation of care plan.
Collaboration with community partners such as VNA agencies, caregiver programs (PCA, ADH, AFC), DME providers, and social service agencies.
Assessment of goal completion and transition of patient to inactive or graduated status as appropriate.
Use reflective, empathetic language and open-ended questions to understand what the patient truly wants beyond health and staying out of the hospital.
Meet the patient where they are; observe without intervention or judgment.
Employ knowledge of common chronic medical conditions in the population served to:
Educate the patient on medication conditions and self-management skills.
Use motivational interviewing to promote behavioral change.
Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
Collaborate with Community Health Workers and/or Social Workers.
Meet regularly with leaders at local clinical sites (Primary Care, ED, inpatient) and care management supervisor, triaging program issues appropriately.
Participate in local site operations, including team meetings, curbsides with care team members, etc.
Participate in planning and growth of the program with relevant stakeholders to respond to evolving needs of MassHealth ACO.
Facilitate interdisciplinary consultation on the patient’s behalf through participation in rounds, team meetings, and clinical reviews.
Comply with established metrics for performance and adhere to documentation and workflow standards.
Maintain HIPAA standards and confidentiality of protected health information.
Adhere to departmental/organizational policies and procedures.
Be available to work at the clinic site on assigned practice days in person.
Metrics
ED and inpatient visits
Total medical expense
Patient satisfaction
Clinical outcomes
Provider satisfaction
Avoidable admissions
Other Duties Other duties as assigned.
Job Requirements Education:
Nursing degree: Diploma, ASN or BSN/Masters (preferred). Ability to obtain BSN within 4 years.
Certificates, Licenses, Registrations Required:
Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts, AND/OR Completed an accredited educational program for Nurse Practitioners.
Experience:
Minimum of two years of clinical experience preferred; care management experience preferred.
Preferred Experience:
Experience working with vulnerable patient populations.
Home care or clinic.
Motivational interviewing.
Clinical experience with patients with multiple complex health issues.
Care management.
Knowledge and Skills:
Excellent interpersonal skills and ability to work collaboratively.
Self-management skills, including ability to prioritize and set patient-centered goals.
Excellent written and verbal communication.
Able to maintain professional boundaries.
Ability to work with diverse, safety-net population.
Skilled at engaging difficult-to-engage patients—build rapport, trust.
Creative problem solver.
Ability to adapt to changes in healthcare delivery at local and systems level.
Extensive knowledge of healthcare systems and community resources.
Ability to leverage systems and resources for improved patient outcomes.
Strong organizational and time management skill.
Equal Opportunity Employer / Disabled / Veterans
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Schedule and Work Setting This position is Monday – Friday, 40 hours FTE, no weekends or holidays observed by BMC. Business hours are typically between 8:30 am and 5 pm. It is a blended hybrid role with opportunities for both in-person and remote work from home. Candidates must have a working vehicle and be able to travel independently. The role serves patients in the Brockton, Randolph, Raynham, Bridgewater, Easton, and Quincy communities. Approximately 2 days per week are worked from home, ~3 days in the community, practice site, or patient home settings. The dress code is business casual.
Team and Collaboration The CCM team will be embedded in local primary care practices and partners closely with PCPs, Integrated Behavioral Health Professionals, Pharmacists, and other local resources to develop multidisciplinary care plans. Nurses proactively seek opportunities to care for patients, including during PC visits, ED or IP visits, out in the community, or on the phone. Nurses will pair with Community Wellness Advocates who focus on social determinants of health.
Compensation Compensation will be based on a salary/incentive plan.
Essential Responsibilities & Duties
Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leaders.
Execute core care management duties, including:
Comprehensive assessment: bio‑psycho‑social‑spiritual.
Collaboration with patient and care team to develop patient-centered care plan, focusing on chronic disease management, social determinants, transitions of care and advanced care planning (HCP, MOLST).
Implementation of care plan.
Collaboration with community partners such as VNA agencies, caregiver programs (PCA, ADH, AFC), DME providers, and social service agencies.
Assessment of goal completion and transition of patient to inactive or graduated status as appropriate.
Use reflective, empathetic language and open-ended questions to understand what the patient truly wants beyond health and staying out of the hospital.
Meet the patient where they are; observe without intervention or judgment.
Employ knowledge of common chronic medical conditions in the population served to:
Educate the patient on medication conditions and self-management skills.
Use motivational interviewing to promote behavioral change.
Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
Collaborate with Community Health Workers and/or Social Workers.
Meet regularly with leaders at local clinical sites (Primary Care, ED, inpatient) and care management supervisor, triaging program issues appropriately.
Participate in local site operations, including team meetings, curbsides with care team members, etc.
Participate in planning and growth of the program with relevant stakeholders to respond to evolving needs of MassHealth ACO.
Facilitate interdisciplinary consultation on the patient’s behalf through participation in rounds, team meetings, and clinical reviews.
Comply with established metrics for performance and adhere to documentation and workflow standards.
Maintain HIPAA standards and confidentiality of protected health information.
Adhere to departmental/organizational policies and procedures.
Be available to work at the clinic site on assigned practice days in person.
Metrics
ED and inpatient visits
Total medical expense
Patient satisfaction
Clinical outcomes
Provider satisfaction
Avoidable admissions
Other Duties Other duties as assigned.
Job Requirements Education:
Nursing degree: Diploma, ASN or BSN/Masters (preferred). Ability to obtain BSN within 4 years.
Certificates, Licenses, Registrations Required:
Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts, AND/OR Completed an accredited educational program for Nurse Practitioners.
Experience:
Minimum of two years of clinical experience preferred; care management experience preferred.
Preferred Experience:
Experience working with vulnerable patient populations.
Home care or clinic.
Motivational interviewing.
Clinical experience with patients with multiple complex health issues.
Care management.
Knowledge and Skills:
Excellent interpersonal skills and ability to work collaboratively.
Self-management skills, including ability to prioritize and set patient-centered goals.
Excellent written and verbal communication.
Able to maintain professional boundaries.
Ability to work with diverse, safety-net population.
Skilled at engaging difficult-to-engage patients—build rapport, trust.
Creative problem solver.
Ability to adapt to changes in healthcare delivery at local and systems level.
Extensive knowledge of healthcare systems and community resources.
Ability to leverage systems and resources for improved patient outcomes.
Strong organizational and time management skill.
Equal Opportunity Employer / Disabled / Veterans
#J-18808-Ljbffr