Pediatric Complex Care Manager, Special Kids Special Care (Boston, South Shore, Metro West Areas)

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. Excellent interpersonal skills, clinical expertise in pediatrics and the ability to work both independently and collaboratively are key requirements of the job.

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.

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 populationsHome care or clinicMotivational interviewingClinical experience working with patients with multiple complexAbility to adapt to changes in healthcare delivery at local and systems levelExtensive knowledge of healthcare systems and community resourcesAbility to leverage systems and resources for improved patient outcomesStrong organizational and time management skillsAccess to personal transportation requiredDigital literacy requiredFluency in a second language is a plus

Key Functions/Responsibilities

Ability to execute core care management duties:Comprehensive assessment: bio-psycho-social-spiritualCollaboration 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 servicesThe individual is responsible for working with patients to identify strengths and barriers and to develop an individualized, patient-centered care plan. Excellent interpersonal skills, clinical expertise in pediatrics and the ability to work both independently and collaboratively are key requirements of the jobHas knowledge of common chronic medical conditions presented in the population served and is able to:Educate the patient and their caregivers on their conditions and medications, and build their self-management skills;Use motivational interviewing to promote behavioral change;Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.Meets regularly with team members and care management supervisor to triage program issues appropriately.Actively participates in planning and growth of program with relevant stakeholders as neededFacilitates interdisciplinary consultation on patient’s behalf through participation in clinical review team (CRT) meetingsThe individual will arrange for case conferences as needed, involving school, day care and early intervention services providers as appropriate.Complies with established metrics for performance and adheres to documentation and work flow standardsMaintains 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 communityOther 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).

Equal Opportunity Employer/Disabled/Veterans