Lahey Health Care Manager, Medicare ACO in Beverly, Massachusetts


Position Summary:

Lahey Clinical Performance Accountable Care Organization (LCP-ACO) participates in a contract with Medicare & Medicaid Services (CMS) to manage the Medicare population attributed to Lahey providers. This contract includes ensuring savings are attained through achievement of quality measures, improving care coordination and providing care that is appropriate, safe and timely. Lahey Clinical Performance Network (LCPN) has oversight of population health and is responsible to ensure that quality, efficient care management services are provided to the Lahey provider?s ACO Medicare high risk population.

The Care Manager, ACO Medicare Population provides transitional and ambulatory care management services to the Lahey primary care physicians focusing on the high risk, high cost, chronic/complex condition patient population. Collaborates with the primary care team to develop care plans on their high risk patient population through care coordination, disease management education and community resource support while enhancing care transitions across the continuum of care. Responsibilities include working with physicians, patients, families, and the multidisciplinary team in the acute care, rehab, skilled nursing facility, homecare, community and physician practice setting to optimize quality and efficient outcomes; and decrease total medical expenses. The care manager assesses, plans, implements, coordinates, monitors and evaluates options and services to meet the individual patient needs. The care manager works closely with the primary care provider and patient to develop collaborative care plans to improve self-management of chronic condition utilizing evidence-based best practice standards. The care manager builds relationships with the patient through use of motivational interviewing techniques to promote engagement in healthy behavior.

The Care Manager ACO Medicare Population upholds the current standards of professional case management practice, and reports to the Director, Ambulatory Care Management, LCPN.

Essential Duties & Responsibilities (including but not limited to):

Ambulatory Care Management: the care manager supports the primary/specialty care physicians in population health management by focusing care coordination attention on the high risk, chronic condition population driving utilization and costs to improve efficiency, quality and patient satisfaction.

Prepares and leads care management rounds at select primary care practices to impact inpatient, ED and outpatient utilization. Engages physician and practice team in proactive patient management by addressing medical /psychosocial/functional health care needs, follow-up, and referrals. Utilizes high risk registry system reports to review high risk population with providers to prioritize program enrollment, care planning, address prognosis and potential palliative/hospice care referrals.

Offers and coordinates free care consultation to complex patient/caregiver in the practice setting or home as necessary to reinforce disease management education utilizing teach back methods or assist with completion of health care proxy, advanced care planning, or community resource navigation.

Develops comprehensive care plans in collaboration with patient, physician and health care team based on evidence-based best practice for chronic illness care. Creates a patient-centered care plan that addresses problems /barriers and develops action plan relevant to obstacles in chronic condition management. Refers patients to appropriate community resources and support programs.

Serves as the central resource for the physicians and practice team for the Medicare ACO population functioning as navigator, coach, and disease manager for the targeted patient population. Collaborates with patients to facilitate healthy behaviors. Utilizes coaching to foster healthy diet, exercise, medication and disease management. Helps patients to learn strategies and skills designed to stabilize symptoms and prevent disease progression.

Reviews high risk/high cost patients with physician to understand drivers of cost, current treatment plan, future course and prognosis. Ensures advance directives and appropriate referrals addressed such as palliative/hospice and makes recommendations for cost reduction alternatives whenever appropriate.

Analyzes retrospective/concurrent utilization and cost data and seizes opportunity to reduce gaps in care by making recommendations for efficiency, quality and cost improvement. Understands organizational goals and accountability towards maximizing organization performance.

Communication: the care manager interfaces daily with patients, families, assigned physicians, the health care team, community agencies, vendors, and health system staff to ensure efficient, quality care delivery.

Reviews high risk cases with Medical Director and physicians in a concise, effective, professional manner. Addresses medical /psychosocial concerns and makes recommendations to improve efficiency and quality care. Serves as an educational/informational resource to physicians, provider care team, and patient/family regarding inpatient/outpatient resources. Participates in care team huddles by communicating important information on high risk cases with interdisciplinary team.

Documents in the case management record clear, concise, timely notes that addresses patient medical/psychosocial problems, barriers, goals, support system, advance directives, transition plan and case management interventions to improve efficiency, quality and reduce cost.

Acute Care Management: the care manager is responsible for managing and ensuring safe and smooth care transitions across the continuum of care for the Lahey ACO Medicare patient population.

Performs timely and accurate daily case reviews targeting the chronic, high risk unplanned medical admissions at home hospitals to identify admission rationale, plan of care and opportunities to improve gaps in care and prevent readmission.

Interfaces with multidisciplinary team including ACO Medical Director, hospitalist, hospital case manager, physical therapist, VNA liaison, pharmacist, social worker and others to proactively address patient/caregiver transition needs, to ensure appropriate level of care and enhance patient care transitions across care settings.

Provides telephonic and/or face to face patient encounter to introduce case manager role and begin patient engagement. Completes comprehensive assessment with patient/caregiver to ensure vital transition components addressed such as medication concerns, social support system, advance directives, service and transportation needs. Addresses routine preventive care at every patient encounter.

Utilizes motivational interviewing to engage patient in dialogue concerning unplanned admission while addressing chronic condition self-management. Reinforces education concerning chronic condition management utilizing evidence-based education tools.

Coordinates timely follow-up with primary or specialty physician to reduce gaps in care and reduce readmission risk. Coordinates VNA, DME and other community services to ensure a safe transition plan.

Proactively screens and refers patients to pharmacist with medication concerns to address cost-effective alternatives and promote medication adherence. Refers patients to social worker to address social needs.

Provides post discharge calls within two business days of discharge to targeted patient population post hospitalization, post-acute care and ED visit to ensure timely follow up with primary/specialty care. Assesses home status, reinforces transition plan and addresses urgent care needs. Proactively intervenes when problems identified with prompt physician communication, access to care and coordination of services.

Patient and Provider Satisfaction: the care manager strives to provide a quality patient and provider experience while working in collaboration with the patient/family and primary/specialty care physician team.

Coordinates care to maximize the value of services delivered to patients to improve health care outcomes.

Incorporates shared decision making in all aspects of patient care interactions. Promotes patient autonomy and self-management at every encounter.

Creates a culturally sensitive care plan while utilizing health literacy and language appropriate patient education materials to promote engagement in plan.

Quality Improvement: the care manager is responsible for timely reporting of quality events in the inpatient/outpatient care setting to ensure continuous monitoring for quality improvement.

Refers quality/risk management cases to Manager, Medical Director and reports events per Lahey policy, regulatory and /or health plan requirements.

Identifies opportunities to improve patient adherence with ACO quality measures. Reports and follows up on patient complaints to ensure quality care and patient satisfaction.

Participates in quality improvement projects and other educational sessions offered by the employer to promote continuous learning.

Organizational Requirements:

Maintains strict adherence to the Lahey Health Confidentiality policy.

Incorporates Lahey Health Standards of Behavior and Guiding Principles into daily activities

Complies with all Lahey Health Policies.

Complies with behavioral expectations of the department and Lahey Health.

Maintains courteous and effective interactions with colleagues and patients.

Demonstrates an understanding of the job description, performance expectations, & competency assessment.

Demonstrates a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.

Participates in departmental and/or interdepartmental quality improvement activities.

Participates in and successfully completes Mandatory Education.

Performs all other duties as needed or directed to meet the needs of the department.


Minimum Qualifications

Education: BSN required. Masters in a health or business field desirable.

Licensure, Certification & Registration: Active, unrestricted Massachusetts Registered Nurse License required.

Certification in Case Management (CCM) preferred.

Must be willing to achieve case management certification (CCM) within 16 months of employment.


  1. RN with BSN and 5 years minimum of both case management and nursing experience.

  2. Excellent clinical, interpersonal and communication skills. Must be able to work collaboratively with other healthcare professionals as well as independently. Experience with coaching while working with the chronic, complex population in a physician management service organization is desirable.

  3. Must be proactive, assertive, and possess creative problem solving skills.

  4. Experience with Medicare population in managed care, medical home or integrated case management environment is preferred.

  5. Must be proficient in computer skills, internet, information technology and electronic medical record use.

  6. Achieves and maintains case management certification within 16 months of employment.

Skills, Knowledge & Abilities:

  1. Strong development, analytic and systems building skills.

  2. Must be facile with physician relations, developing systems and procedures, developing and operating a capitated managed care infrastructure, continuous quality improvement, human resources management and fiscal management.

  3. Excellent written and verbal communication skills. Must have a professional demeanor and the ability to deal with physicians, senior management, and local industry.

  4. Capable of serving as a spokesperson and leader of the integration process and communicate the vision to others in the community.

  5. A well-defined style that demonstrates confidence, maturity, self-motivation, high energy, collaboration, high intellect and leadership qualities.

  6. Excellent interpersonal skills, be an appropriate risk taker, politically savvy, diplomatic, able to deal with ambiguity, flexible, organized, results oriented, a hard worker, a quick study, good with details and have integrity.

  7. Ability to function as a facilitator who can further the organization to serve the evolving Network.



About Lahey Health

The Lahey Model of Care - right care, right time, right place - is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.

Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.

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