SCO Nurse Care Manager - Bilingual preferred - Springwell Metrowest (Framingham, Marlborough, South/North/Westborough, Hudson, Sudbury, Wayland, Ashland, Natick)

About the role

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health . Job Summary The Care Manager - Nursing (RN CM) will ensure that all members receive timely care management (CM) across the continuum, including transitions of care, care coordination and navigation, complex case management, population health and wellness interventions, and disease/chronic condition management per department guidelines. The nurse care manager possesses strong clinical knowledge, critical thinking skills, and ability to facilitate a care plan which ensures quality medical care for the member. The RN CM works closely with the member, the caregiver/authorized representative, and providers to meet the targeted member-specific goals. Based on national standards for CM practice, the RN CM focuses on empowering the member to support optimal wellness and improved self-management. Job Description Key Responsibilities/Duties - what you will be doing Perform telephonic member outreach and/or face-to-face encounter utilizing key motivational interviewing skills to facilitate program enrollment. Perform departmental assessments and evaluate member holistically to identify needs, health goals, and barriers to wellness. Through assessment and collaboration with member/caregiver and providers, develop a member-specific plan of care, implement member-specific care manager interventions, and revise plan of care as needed. Complete documentation in applicable platform according to departmental policy and regulatory standards. Provide targeted health education, proactive strategies for condition management, and communication with key providers and vendors actively involved in the member's care. Collaborate with member/caregiver and the facility care team to coordinate a safe transition to the next level of care, which includes but is not limited to ensure understanding post-hospital discharge instructions, facilitate needed services and follow-up, and implement strategies to prevent re-admission. Collaborates and liaises with the interdisciplinary care team, to improve member outcomes (i.e., Utilization Management, Medical Director, pharmacy, community health workers, dementia care specialists, wellness, and Behavioral Health CM). Attending and presenting (as appropriate) high risk members at interdisciplinary rounds forum. Maintain professional growth and development through self-directed learning activities. Qualifications - what you need to perform the job Certification and Licensure Registered Nurse with current unrestricted license in state of residence May be required to obtain other state licensure in states where Point32Health operates Understand and follow the provisions of state-specific Nurse Practice Act(s) where Point32Health operates National certification in Case Management desirable Education Required (minimum): Bachelor's degree or relevant equivalent experience Preferred: Bachelor's degree in nursing