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Steward Health Care System Remote Patient Monitoring Care Manager (RN) in Westwood, Massachusetts

Steward Health Care Network (SHCN) takes pride in its community-based care model, which drives value-added tools and services to our communities, patients, physicians, and hospitals across the continuum of care. In addition, Steward Health Care Network promotes care coordination and collaboration within the network in order to provide high-quality, efficient care to patients. With Steward in the community, all residents can be sure that there is a world-class doctor close to where they live.

The network is also responsible for the implementation and execution of our managed care contracts, medical management services, quality improvement programs, data analysis, and information services.

Position Purpose: The Remote Patient Monitoring Care Manager is a Registered Nurse (RN). This role may utilize, among other tools, device and/or deviceless RPM technology to identify and outreaching high-risk and rising risk patients discharged from acute settings and to reduce readmissions in that patient population. The RPM Care Manager leverages technology and health record systems to 1.) identify pain points and care breakdowns in transitions of care by using remote patient monitoring and electronic health records; 2.) appropriately elevate clinically rising risk members for further mitigation by licensed health care providers to promote a positive patient experience and decrease excessive unwarranted utilization of care such as inappropriate emergency room access and inpatient admissions. This role provides support to the clinical team including case management divisions, nurse practitioners, physician assistants, primary care providers, and non-clinical personal both in the acute and ambulatory settings.

This position will involve telephonic management of patients and the ability to leverage and document in multiple health record systems and will require some day-time weekend coverage.

  • Executes value-based strategies that focus on high quality, cost-efficient care, including but not limited to:

  • Patient identification

  • Performs patient centered standardized assessments to identify barriers that have been elected through pre-screened assessments via technology

  • Participates in the coordination across the care continuum with the patient’s primary health system and transitional teams

  • Patient (and caregiver/family) education

  • Refers member beneficiaries to appropriate SHCN Care Management Programs, provides warm handoff

  • Develops strong working relationships with internal and external teams to meet goals

  • Uses data and clinical expertise to drive program performance communicating with key internal and external stakeholders to assist in continually improving clinical care and performance using best practices

  • Meets regularly with internal / external staff to review data and develop strategies that drive continuous improvement

  • Works with management and is responsible for monthly performance targets based on real time metrics as well as claims-based data

  • Understands and is able to articulate the value of Steward Health Care to patients and families while maintaining a patient's right to choose

  • Tracks feedback received from patients, families and others regarding programs and preferred facilities for process improvement opportunities

  • Completes documentation in established health record systems as indicated

  • Is integral in working with leadership and IT departments to ensure the maintenance of care management databases and use of care management documentation systems. Proactive about identifying and advocating for system enhancements that may be required to deliver high quality care management services. Collaborates with IT teams to implement, test, and deploy system upgrades and enhancements

  • Responsible for the continuous involvement in Care Improvement (LEAN) initiatives and principles related to achieving quality and patient satisfaction outcomes

  • Demonstrates leadership that creates and fosters a culture of continuous improvement

  • Performs all job functions in compliance with applicable federal, state, local, and company policies and procedures

  • Other duties as assigned

    Education / Experience / Other Requirements

    Education:

  • Certified RN

  • Minimum 4-year degree

  • Broad clinical background desired

    Years of Experience:

  • Minimum three-five years' experience in care management role (preferably in a mixture of ambulatory and hospital settings)

    Specialized Knowledge:

  • Excellent critical-thinking, observation, written /verbal skills, problem-solving, and analytical skills.

  • Ability to lead and motivate others to execute a plan in a rapidly changing environment

  • Ability to work collaboratively with health care professionals at all levels to achieve established goals and improve quality outcomes. Highly organized and ability to work autonomously

  • Knowledge of governmental rules and regulations and hospital standards

  • Strong current working knowledge of Accountable Care Organization (ACO) desirable

  • Knowledge of leading practice in clinical care and payer requirements

  • Familiarity with the compliance and regulatory standards governing health plans and patient care including NCQA, URAC, federal, state, and other regulatory requirements

  • Ability to use Microsoft Office tools including Word PowerPoint, Excel, and Outlook

  • Must be proficient with EHRs and/or other patient tracking/monitoring software

  • Current clinical license

  • Valid driver's license and an insured vehicle in proper working order for local travel

    Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.

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