Complex Care Manager - Pediatrics - SKSC -South Shore

Special Kids, Special Care Program- Covering the South Shore and Cape Cod.
The Complex Care Manager works with relevant stakeholders to engage patients in care management with a focus on patient experience and improving health. This role will be part of an interdisciplinary team serving culturally diverse families with chronic illnesses, special needs, and a variety of neurodevelopmental and related diagnoses. Excellent interpersonal skills, clinical expertise in pediatrics and the ability to work both independently and collaboratively are key requirements of the job.

ESSENTIAL RESPONSIBILITIES / DUTIES:

This position will act as the key medical care manager for pediatric patients with medical and psychosocial complexity. The Complex Care Manager works with relevant stakeholders to engage patients in care management with a focus on patient experience and improving health. This role will be part of an interdisciplinary team serving culturally diverse families with chronic illnesses, special needs, and a variety of neurodevelopmental and related diagnoses. The individual is responsible for outreach to families, meeting with families during clinic sessions, and making home visits in the community. Using the information gathered from the family and the medical team, the care manager is responsible for developing and implementing an individualized, patient-centered care plan. Implementation of the care plan may involve: working with partnering organizations to ensure the child is receiving necessary services, assisting families in interactions with school system and community agencies, and acting as a liaison with the child’s insurance plan. Excellent interpersonal skills, clinical expertise in pediatrics and the ability to work both independently and collaboratively are key requirements of the job.

Key Functions/Responsibilities:

Ability to execute core care management duties:
Comprehensive assessment: bio-psycho-social-spiritual
Collaboration with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning.
Collaboration with program stakeholders and community partners.
Coordinates with health care providers to make sure needs are being met.
S/he will also work with partnering organizations to make sure that children have all needed medical services

Complies with established metrics for performance and adheres to documentation and work flow standards
Maintains HIPAA standards and confidentiality of protected health information.
Follows established infection control and safety procedures.
Adheres to departmental/organizational policies and procedures.
Care Manager will work full-time from their home and visit patients in the community
Other duties as assigned

Must adhere to all of BMC’s RESPECT behavioral standards.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

BS Nursing

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts.

A valid MA Driver's License and access to reliable transportation is required

EXPERIENCE:

A minimum of 3-5 years of pediatric clinical experience is required, with direct care experience in a pediatric outpatient, community or multidisciplinary setting preferred.

Preferred experience:

Experience working with vulnerable patient populations
Home care or clinic
Motivational interviewing
Clinical experience working with patients with multiple complex
Ability to adapt to changes in healthcare delivery at local and systems level
Extensive knowledge of healthcare systems and community resources
Ability to leverage systems and resources for improved patient outcomes
Strong organizational and time management skills
Access to personal transportation required
Digital literacy required
Fluency in a second language is a plus

Equal Opportunity Employer/Disabled/Veterans