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POSITION SUMMARY:

The LTSS (Long Term Support Services) RN oversees the provision of holistic LTSS care management services for Enrollees throughout enrollment with Boston Allied Partners (BAP) by assessing the Enrollee clinically as well as Enrollee's readiness to make behavioral changes and actively participate in a care plan, establish goals and meet those goals. BAP Enrollees may include those who have chronic conditions and complex care needs, including those considered to be the highest risk Enrollees those who are homeless, undergoing organ transplantation, have multiple clinical and behavioral co-morbid conditions, and with special health care needs.

The clinician works collaboratively with a multidisciplinary team (both internal and external) including providers, our clinical vendor partners (behavioral health, pharmacy, etc.) and community/state agencies to increase patient knowledge, motivation, and compliance with treatment through targeted interventions that address the Enrollee's holistic needs from a medical and psychosocial/socioeconomic standpoint. Following this approach, the goal is to improve Enrollee health outcomes and decrease overall costs while improving the Enrollee's overall experience with the health care delivery system. Utilizing both telephonic outreach and face-to-face Enrollee visits and through the use of assessments, real-time data, motivational interviewing techniques and evidence-based practices, the LTSS RN supports Care Coordinators in engaging with the Enrollee and the multidisciplinary team to develop a comprehensive, person-centered Care Plan (CP). Said care plan emphasizes self-management goals, care coordination, psychosocial, socioeconomic, and community-based supports, ongoing monitoring, and appropriate follow up.

The LTSS RN identifies and addresses barriers to optimal self-management and works with the Enrollee, their support persons, and team to coordinate care throughout the health care continuum, assisting the Enrollee to access all available benefits and resources including family support and community resources. The goal is promoting appropriate utilization of services at the appropriate level and site of care such as preventing ambulatory sensitive emergency department visits and inpatient admissions, avoiding readmissions, and encouraging the Enrollee to keep scheduled outpatient appointments to include preventive care visits. The LTSS RN may meet Enrollees in their homes, shelters, provider offices, medical facilities, and at locations agreed upon with the Enrollee.

Position: Registered Nurse

Department: Long Term Support Services - BAP Program

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Key Functions/Responsibilities:

• Completes a targeted comprehensive assessment (CA) and applicable condition-specific assessments on Enrollees upon admission to BAP and at least annually thereafter
• Evaluates Enrollee's need for complex care management, disease management, or chronic condition management.
• Collaborates with Care Coordinator to develop an individual care plan with the Enrollee focusing on the Enrollee's goals and objectives, identifying strategies, supports, and/or services needed to achieve short- and long-term goals
• Identifies and addresses barriers to optimal self-management and works with the Enrollee and team to coordinate care throughout the health care continuum.
• Assists the Enrollee to access all available benefits and resources including family support and community resources.
• Utilizes motivational interviewing techniques to engage Enrollees in care management and to coach Enrollees regarding health promotion, disease management, and preventive health.
• Uses real-time data from electronic medical records, where available.
• Uses eHana reporting to access Enrollee medical and pharmacy utilization reports, sharing with PCP, to promote medication compliance and action plans.
• Supports and enhances the Enrollee's capacity to self-manage.
• Evaluates the effectiveness of the care management provided to the Enrollee on an on-going basis and updates the ICP accordingly.
• Utilizes evidence-based practices and guidelines to educate Enrollees on specific disease processes.
• Provides or arranges for resources necessary to meet Enrollees' psychosocial and socioeconomic needs.
• Promotes and encourages Enrollee collaboration with the primary care provider and other health care providers.
• Completes documentation in the medical management information system real-time during face-to-face meetings, by phone, and in a timely manner and in keeping with contractual requirements and internal policy.
• Facilitates multidisciplinary consultation on Enrollees' behalf through participation in rounds, team meetings and clinical reviews.
• Conducts face-to-face visits with Enrollees and providers, community and state agencies, as appropriate.
• Assists with staff training and mentoring.
• Consults with and refers Enrollees to the multidisciplinary team, as appropriate.
• Coordinates Enrollee care transitions through pre-admission assessments, post-discharge assessment and follow-up to ensure appointment is made with the PCP or Specialist; assessing for home health services, DME needs, and transportation issues; performing medication reviews; ensuring compliance with discharge plan, appointments, and medication regimen.
• Uses available standardized educational materials in an appropriate reading level to educate Enrollees about their conditions.
• Monitors Enrollees' labs, tests results, appointments and other data in order to coordinate care effectively, utilizing EMR (where available and appropriate) and the BAP's care management software.
• Maintains HIPAA standards and confidentiality of protected health information.
• Demonstrates strong knowledge of contractual requirements.
• Participates in after-hours on-call coverage rotation when requested.
• Adheres to departmental/organizational policies and procedures.
• Other duties as assigned.

Supervision Received:

• Weekly and ongoing from Program Manager

JOB REQUIREMENTS

EDUCATION:

• RN License (MA); Bachelor's degree in nursing or Associate's degree in Nursing and relevant work experience

EXPERIENCE:

• Behavioral Health and/or Pediatric experience strongly preferred
• 3 years of related experience in home health care or managed care organization
• 3 years of clinical experience with members who have multiple, chronic or complex health conditions
• 2 years of experience in care management, care coordination, and/or discharge planning

Preferred/Desirable:

* Experience working with Medicaid recipients and community services

* Experience with Epic, eHana, CCMS, SFTP, or other EHR system or healthcare database

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• 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 members, providers, community and state agencies

KNOWLEDGE AND SKILLS:

• Strong Motivational Interviewing skills
• Strong oral and written communication skills
• Ability to effectively collaborate with health care providers and all members of the multidisciplinary team
• Strong technical skills and ability to document in the Plan's care management documentation system in real-time when meeting with members and providers in-person or by phone.
• Demonstrated organizational and time management skills
• Able to work in a fast-paced environment and multi-task
• Experience with Microsoft Office applications, particularly MS Outlook and MS Word and other data entry processing applications
• Strong analytical and clinical problem-solving skills Working Conditions and Physical

Effort:

• 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 when conducting face-to-face visits.
• Face-to-face visits may be conducted in a member's home, shelters, physician practices, hospitals, or at a mutually agreed upon location between the member and the care manager and with community and state agencies, as appropriate.
• No or very limited physical effort required. No or very limited exposure to physical risk.

Equal Opportunity Employer/Disabled/Veterans