The LCHC Director of Care Management Programs oversees the Care Management functions of Complex Care, Transitions of Care, Behavioral Health Community Partners (BHCP) RN Care Managers, and One Care teams at the health center, providing direction, support and coordination of all assessments and care planning/care coordination services provided to those LCHC patients. The Director of Care Management programs oversees daily operations of the programs he/she oversees. In addition, the the Director also may provide skilled nursing care, education, care management and coordination of the plan of care for a specified population of patients in need of intensive care management. The Director will work closely with the Nurse Care Managers, Social Service staff, Community Health Workers, and their immediate supervisors in these programs. He/she will promote and clarify these programs and services to providers, LCHC staff, and eligible patients. The Director of Care Management Programs will collaborate with LCHC staff to develop protocols and workflows that support Care Management at LCHC. This individual will serve as a role model for Care Management staff, and may make home visits when appropriate.
The Director of Care Management participates in LCHC community outreach efforts, as appropriate and as assigned. This may include serving as a health consultant for the Lynn Public Schools, local day care centers, after school program, day camps or other community related organizations; providing such services as programmatic consultation, preparation/review of health related policies and documentation or participating in health screenings, health education programs or counseling at health fairs and other similar community events
- Respect and maintain patient confidentiality in all aspects of care including use of electronic information.
- Treat all patients in a welcoming and professional manner.
- Demonstrate professionalism by appropriate attire, attendance, attitude, and behavior within the clinical setting.
- Contribute to the team effort by supporting all team members and maintaining an open and positive attitude.
- Welcome new employees to the team by assisting with their orientation to the team and mentoring them, as requested.
DUTIES AND RESPONSIBILITIES:
I. Oversees coordination of Care/Care management for patients to ensure continuous, comprehensive care:
- Collaborates with members of the Care Management team to develop and revise workflows.
- Provides direction, support, and clinical/administrative supervision to department staff and their supervisors.
- Reviews cases and meets with Care Management staff on a regular basis.
- Participates in the researching, evaluation and recommendation of community resources to meet needs of patients, i.e. alternative resource programs, support groups and community support resources.
- Collaborates with the PCP, BH providers, outside agency/hospital staff, and other nursing staff at LCHC to ensure efficient use of resources.
- Makes onsite or home visits as indicated.
- Works with Care management staff and other stakeholders to support the identification and triage of those patients who would benefit from a care management model.
- Develops workflows and protocols to meet requirements of program purposes and goals in collaboration with other LCHC departments/staff as appropriate.
II. Functions as a NCM to a specified population of patients in need of intensive care management:
- Completes a comprehensive assessment on eligible patients.
- Evaluates the needs of the patient, develops and implements a plan of care that optimizes outcomes in conjunction with the PCP. The plan reflects goals identified by the care manager, the patient, family, PCP and other providers involved in the patient’s care.
- Makes home visits as appropriate to monitor patient’s clinical status. Assesses the status of identified problems, response to treatment, compliance with therapeutic regimes and medications and progress towards goals. Refers to the primary care provider and team as needed.
- Provides expert nursing care as appropriate.
- Participates in the planning, implementation and coordination of health education and counseling of the patient and family. Teaches families and caretakers how to provide safe, effective care and promote optimum function for patients in the home. Documents the level of understanding and response to teaching.
- Advocates for patients in a culturally competent manner.
- Ensures that patients’ rights to fair and equitable treatment and self determination are well established and maintained.
- Seeks maximum patient and family participation and independence.
- May manage a small caseload, establishing a daily work plan based on patient priorities of service and caseload needs.
- Provides telephone triage for clinical concerns of patients, care providers, family and significant others.
III. Maintains appropriate written and oral communication on a timely basis:
- Documents patient encounters within established timeframes.
- Reviews and assures updates to the care plan appropriately.
- Documentation is clear, objective and reflects the delivery of safe, quality care.
- Reviews communication re: the patients’ clinical status to the PCP on a regular basis.
- Assures the prompt communication regarding changes and/or new problems to the PCP.
- Establishes and maintains an ongoing positive working relationship with all members of the health care team.
IV. Participates in assessing and improving quality within the scope of responsibilities and throughout the organization as appropriate:
- Participates in quality improvement activities as required.
- Participates in program planning activities as required.
- Advises appropriate personnel of quality issues and problems and makes recommendations for improvement.
- Meets regularly with department staff to assure coordination, maintenance of program, and program goals.
- Demonstrates an understanding of customer service principles by successfully completing on-line Customer Service training.
- Utilizes the principles of customer service when interacting with patients/clients, team members and staff from other departments.
- Appropriately handles or seeks support when customer service breakdowns occur.
- Demonstrates knowledge of culture by successfully completing the on-line training on Cultural Competence.
- Utilizes an appreciation of and respect for diversity when interacting with patients/clients, team members and staff from other departments.
- Responds appropriately or seeks support when confronted with cultural biases or conflicts.
- Is aware that in order to respond promptly and appropriately to emergencies, any staff member may be assigned duties that differ from those in the job description, or may be assigned temporarily to a different location or schedule.
- Understands that all staff should have a Personal Emergency Plan in place to best respond to his/her job responsibilities should health center emergency arise.
- Complex Care team, One Care team, Transition of Care RN, Behavioral Health Community Partner RNs
- RN with current Massachusetts License.
- CCM required.
- Bilingual preferred.
- Bachelors Degree in Nursing from an accredited program required, Masters Degree preferred.
- History of good attendance and a positive work attitude
- Strong organizational and communication skills and understanding of High Risk patients.
- 5 years clinical experience in Care Management preferred, including in-patient and community-based work.
- Experience in home care and/or community settings preferred.
- Strong behavioral health experience preferred.
- Proven skills and knowledge base necessary for clinical decision making and care delivery.
- Ability to function independently and seek assistance with unusual problems.
- Strong interpersonal and customer relations skills.
- Effective teaching skills.
- Experience in electronic health records, including managing multiple platforms required by care management programs.
- Demonstrated supervisory or program management experience.
- The essential duties of this position present risk of exposure to airborne infection, body fluids, and blood-borne pathogen.
- Annual BBP Training is required.
- Up to date immunization and annual TB testing is required.
- Hepatitis B vaccine and annual flu immunization are strongly recommended. All necessary vaccines are available at no charge at the health center.
- A Declination form must be signed if the Hepatitis B or other recommended vaccines are declined.
- Results of inquiry to Criminal Offender Record Investigation (CORI) must be acceptable under health center standards.
Lynn Community Health Center (LCHC) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, LCHC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, and transfer, leaves of absence, compensation and training. LCHC expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of LCHC’s employees to perform their job duties may result in discipline up to and including discharge.
Job Posting ID#: 18-049