Partners HealthCare is a not-for-profit health care system that is committed to patient care, research, teaching, and service to the community locally and globally. Collaboration among our institutions and health care professionals is central to our efforts to advance our mission.
The Integrated Care Manager (ICM) may be embedded in select NWPHO affiliated primary care practice(s) and will collaborate with the primary care physicians and other members of the patient’s care team to plan and implement optimal and efficient care plans and design approaches to care for a defined population of patients managing their care across the continuum.
This position requires a broad knowledge of clinical care, available health services across the continuum of care, insurance benefit design and reimbursement methods, care integration systems and management and experience in acute care or community case management.
The ICM will demonstrate prudent nursing judgment, effective problem solving skills, critical thinking, excellent organizational and interpersonal skills, creativity, flexibility, and the ability to multi-task.
The ICM will update and educate him/herself in matters relating to care coordination, applicable Federal and State regulations, risk management, community resources and other pertinent topics.
Major duties and responsibilities:
Care Management: Communication/Coordination
Routinely consults with the patient’s PCP, mental health and specialist physicians as well as other members of the PCMH team to identify and validate high priority patients.
Conducts outreach and completes assessments for patients identified in benefiting from care coordination services. Outreach may be telephonic, electronic or in person contact.
Develops a patient centered plan of care and provides patient/family health education and coaching for an identified panel of patients
Incorporates self-care and promotes shared decision making in all aspects of patient care.
Serves as a key resource to an assigned group of patients in one or more primary care practices, helping to proactively address their questions, concerns and care needs by guiding and facilitating access to providers and services.
As appropriate, directly provides ongoing community based care management services and/or refers patients to other care management programs such as provider-based disease management programs or insurance-based specialty case management programs.
Establishes a consistent schedule of communication and reporting with involved providers and the patient with intended goal of reviewing patient status and progress toward goals.
Collaborates with and seeks feedback from primary care physician, interdisciplinary team and/or the community care management leadership team regarding challenging patient situations.
Communicates with other health care clinicians throughout the continuum about patient’s care needs, utilization plan and applicable follow up plans.
Incorporates knowledge of case management standards, payer rules and coverage, and utilization management principles to implement high quality, cost effective care plans.
Provides information and education as necessary to other members of the care team regarding insurance benefit design and coverage, health care options and available community resources.
Influences appropriate utilization of health care resources by coordinating patient care across the continuum, encouraging involvement in disease and case management programs and conducting follow-up care prior to and post interaction with the broader health care system including acute care admissions, emergency department visits, specialist visits, and sub-acute care settings.
Using medical management criteria and/or other Partners approved diagnostic screening criteria, collaborates with hospital and/or sub-acute staff to understand the appropriateness of hospital and/or sub-acute admissions, length of stay and readmissions.
Authorization and coordination of services which may include; determining appropriate level of care, management of patient’s health benefits, authorization for approved services in compliance with federal and state standards and in compliance with health plan guidelines as appropriate as well as referrals to community agencies.
Notifies the primary care physician and care team, iCMP manager and/ or NWPHO leadership regarding over and under utilization of services including patient specific factors which may influence utilization patterns.
Works with the interdisciplinary team to assess the needs of patients in the home, office practice, emergency department or hospitalized in observation status, who may be appropriate for a direct admission to a skilled nursing facility.
RN graduate of an accredited school of nursing and currently licensed to practice in Massachusetts.
Minimum of 5 years experience in hospital, health plan or community case management or utilization management role.
Preferred qualifications include:
BSN, BS or BA
Certification in case management (CCM), (ACM) or other applicable professional certification
Previous experience working in a post acute setting such as LTAC, acute rehabilitation, skilled nursing facility, or homecare.
Previous experience working in an ambulatory setting such as a health center or physician’s practice.
Managed care or health care reimbursement experience with a working knowledge of nationally accepted utilization review criteria (InterQual, Milliman).
Evidence of continued education and professional development.
Shift: Day Job