Nurse Care Manager (Senior Care Product) – Field Based

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

WellSense Health Plan is recruiting for motivated, compassionate, mission-driven nurses to join our Senior Care Options (SCO) program clinical team. The SCO program is designed to deliver high-quality, compassionate care to seniors in their home. We’re looking for nurses who are driven by a passion to serve the under-served and are committed to making a difference in elders’ lives. 

The Care Manager serves a central role on an interdisciplinary team committed to helping seniors stay in their communities and maintain their independence. The Care Manager acts as the clinical link with the member’s Primary Care Team (PCT) which includes the Member, Caregiver(s), Primary Care Provider, community agency providers, pharmacists, social workers, and others involved with the Member’s care. 

The Care Manager’s work is primarily conducted in the field and includes a variety of diverse and complex face-to- face and telephonic care management responsibilities. The Care Manager provides care coordination for at-risk and complex individuals through a member-centric, team-based approach. The Care Manager ensures the right care is provided in the right setting and at the right time.   

Responsibilities include assessment, the development, implementation, and evaluation of the Individual Plan of Care (IPC) and managing the member’s care through the health care continuum. Perform other duties as requested. 

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

Key Functions/Responsibilities:

• Manages a panel of high risk, medically complex members
• Completes timely initial and on-going face-to-face comprehensive assessments with Member to evaluate Member’s medical, behavioral health, functional status, and socioeconomic needs
• Administers MDS-HC assessments and other required assessment tools
• Facilitates meetings of the PCT and serves as clinical subject matter expert and advocate for Member
• Develops and communicates an Individual Plan of Care (IPC) with Member, caregiver(s), providers and other PCT members to address identified needs and ensures its implementation
• Utilizes evidence-based guidelines to develop Individualized Plans of Care (IPC)
• Evaluates the effectiveness of the IPC and progress against goals and reviews the IPC as needed
• Utilizes evidence-based guidelines to assist Member in understanding their disease process and increase their capacity for self-management and optimal health
• Utilizes data to ensure that clinical interventions result in improved clinical outcomes and appropriate utilization of services at the right time, right place, and right setting
• Evaluates the effectiveness of alternative care services and ensures that cost effective, quality care is
• Facilitates Member and caregiver access to community resources relevant to the Member’s needs
• Documents clinical assessments and coordination of care in the medical management information system in a timely manner that meets regulatory and accreditation standards
• Provides culturally competent care coordination in keeping with the Member’s racial, ethnic, linguistic and sexual orientation
• Facilitates sharing of essential clinical or psychosocial information related to the Member’s care
• Must become knowledgeable in the full contractual requirements of the Care Management agreement with EOHHS and CMS (D-SNP Agreements)
• Must become proficient in contracts with vendors and agencies of whom the company outsources for the population
• Maintains HIPAA standards and confidentiality of protected health information
• Reports critical incidents and information regarding quality of care issues
• Serves and participates in pertinent committees and meetings as needed
• Assists with new staff training
• Must use a cell phone and provide on-call services, per a rotating schedule
• Regular and reliable attendance is an essential function of this position
• Other duties as assigned 

Qualifications:

Education:

• Registered Nurse
• Bachelor’s degree or an equivalent combination of education, training and experience is required

Preferred/Desirable:

• 3 years’ experience in Medical Case Management working with the geriatric population, preferred
• Master’s degree in nursing, geriatric NP, or health related/public health field preferred
• Certification in case management (CCM) preferred

Certification or Conditions of Employment:

• Active Massachusetts RN license required

Competencies, Skills, and Attributes:

• Strong knowledge and use of the MDS-HC assessments and other required assessment tools
• Excellent clinical and assessment skills
• Experience with the Medicaid, Medicare, and Senior population
• Experience with ASAPs preferred
• Ability to work collaboratively and build strong relationships with providers, Members, and the PCT
• Proficiency in InterQual Level of Care through the continuum
• Excellent working knowledge of Windows and Microsoft Office products
• Must have the ability to use a laptop, or tablet for accessing the company systems to include documentation in the medical management information system
• Flexible, independent, self-starter with an ability to thrive in a fast paced environment
• Demonstrates commitment to quality
• Projects positive, team-oriented demeanor
• Demonstrates strong interpersonal skills including effective listening and ability to support, motivate and guide others
• Strong oral and written communication skills; ability to interact within all levels of the PCT
• Demonstrated ability to successfully plan, organize and manage within a person centered integrated care team
• Detail oriented

Working Conditions and Physical Effort:

• Attendance and participation at PCT meetings required which may include early mornings or evenings
• Travel within the SCO geographic network required

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.