WellSense Health Plan is a nonprofit health insurance company serving members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, regardless of their circumstances.
It’s an exciting time to join WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing effective health coverage for our members.
Job Summary
The Clinical Care Manager provides holistic medical care management services for members throughout the continuum of care by assessing the member clinically and their readiness to make behavioral changes, actively participate in a care plan, establish goals, and meet those goals. Members may include those with chronic conditions and complex care needs, including high-risk members such as the homeless, organ transplant recipients, individuals with multiple clinical and behavioral co-morbidities, and those with special health care needs. The clinician collaborates with a multidisciplinary team (internal and external), including providers, clinical vendor partners (behavioral health, pharmacy, etc.), and community/state agencies to increase patient knowledge, motivation, and compliance with treatment through targeted interventions addressing medical, psychosocial, and socioeconomic needs. The goal is to improve health outcomes, reduce costs, and enhance the member’s experience with healthcare services.
Using telephonic outreach and face-to-face visits, assessments, real-time data, motivational interviewing, and evidence-based practices, the Clinical Care Manager develops an Individual Care Plan (ICP) emphasizing self-management, care coordination, psychosocial and socioeconomic supports, and ongoing monitoring. They identify and address barriers to self-management, coordinate care across the healthcare continuum, and facilitate access to benefits and resources, including family support and community services. The aim is to promote appropriate utilization of services, prevent unnecessary emergency visits and hospitalizations, and encourage adherence to scheduled outpatient and preventive care appointments. Members may be met in their homes, shelters, provider offices, or other locations agreed upon with the member.
Our Investment in You
Key Functions/Responsibilities
* Complete targeted assessments, including condition-specific ones.
* Evaluate members’ needs for complex care, disease management, or chronic condition management.
* Develop an individualized care plan with the member, focusing on their goals and strategies to achieve them.
* Identify and address barriers to self-management and coordinate care across the healthcare continuum.
* Assist members in accessing benefits and community resources.
* Use motivational interviewing to engage members and promote health and disease management.
* Utilize real-time data from electronic medical records and reports to inform care strategies.
* Support medication compliance through sharing utilization reports with providers.
* Encourage and support member self-management capacity.
* Continuously evaluate and update the care plan based on effectiveness.
* Educate members on disease processes using evidence-based practices and materials appropriate to their literacy level and language.
* Address social determinants of health, including psychosocial and socioeconomic needs.
* Foster collaboration with primary care providers and other healthcare professionals.
* Document all interactions promptly in the medical management system, adhering to standards and policies.
* Participate in multidisciplinary team meetings and consultations.
* Conduct face-to-face visits with members and providers, including community and state agencies.
* Maintain reliable transportation to conduct face-to-face appointments.
* Assist with staff training and mentoring as needed.
* Refer cases to specialized care management teams when appropriate.
* Coordinate care transitions, including pre-admission assessments, discharge planning, and follow-up.
* Monitor labs, test results, and appointments to coordinate ongoing care.
* Maintain confidentiality and HIPAA compliance.
* Demonstrate knowledge of contractual requirements across product lines.
* Perform other duties as assigned, including care management for infants with low birth weight or NAS, and coordination with families and providers for safe care planning.
Supervision Received
* Regular meetings with the Care Management Manager.
Qualifications
Education: Bachelor’s degree in nursing or an Associate’s degree in Nursing with relevant experience.
Experience: At least 3 years in home health or managed care, 3 years in clinical care for complex conditions, 2 years in care coordination/discharge planning, experience with Medicaid and community services, familiarity with healthcare databases (FACETS, Jiva, Interqual), CCM certification preferred.
Licenses/Certifications: Valid unrestricted RN license, background check, reliable transportation.
Skills and Attributes
* Strong motivational interviewing skills.
* Excellent communication skills.
* Ability to collaborate effectively with healthcare teams.
* Organizational and time management skills.
* Proficiency with Microsoft Office and healthcare data systems.
* Analytical and problem-solving skills.
* Ability to document in real-time during interactions.
Working Conditions
* Regular attendance required.
* Work may be in an office or home environment, with face-to-face visits in various community settings.
* Limited physical effort and risk involved.
About WellSense
WellSense serves over 740,000 members across Massachusetts and New Hampshire with Medicare, Medicaid, and individual plans. Established in 1997, we are committed to diversity and inclusion. We are an equal opportunity employer and participate in E-Verify. Beware of employment scams; apply only through our official website and do not pay for job offers.
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