The Transition to Home (TTH) Clinician outreaches to members post discharge from the acute care setting, utilizing motivational interviewing to educate and ensure compliance with post discharge regimens, improve self management of chronic, targeted conditions (specific diagnoses within a number of DRGs causing the highest number of readmissions) and medication reconciliation.
Contacts identified members telephonically within two business days of known discharge to engage member in the full TTH Program and follows members intensely for 31 to 45 days (based on needs and complexity) to decrease likelihood of readmission.
Ensures a post-discharge appointment is made with the PCP or Specialist, along with assessing for VNA/Home Health services, DME needs, and transportation issues.
Coordinates care necessary after discharge and makes referrals to the TTH Coordinator for Community services (transportation, food, etc).
Conduct an assessment of conditions (and depression screening), including those not being treated for in the inpatient setting.
Develops and Individual Care Plan (ICP) with the member and collaborates with the member’s physician(s) to discuss needs and offer potential solutions to clinical and/or social obstacles. The ICP should contain educational goals as needed on disease process.
Ensure compliance with discharge plan by maintaining regular contact with the member, reinforcing importance of medication compliance, attending all set appointments, and reviewing previous areas of education provided telephonically or via Krames materials sent to the member.
Researches all aspects of Member care to review member needs. These include (but are not limited to): pharmacy profile, claims, authorizations, hospitalizations and physician specialty services to review member needs.
Conducts medication reconciliation and refers to Plan Pharmacists as needed.
Assesses the members’ need and refers for continued Medical or Behavioral Health Care Management services when member completes TTH program.
General supervision received weekly
Bachelors Degree in Nursing or Nursing School Degree with equivalent, relevant experience.
3 years related experience in an acute care or health insurance environment
2 years experience with case management, care coordination, and/or discharge planning.
Experience with Medicaid recipients and community services.
Experience with CCMS, FACETS, or other healthcare database.
Certification or Conditions of Employment:
Current MA state licensure as a Registered Nurse.
Pre-employment background check.
Competencies, Skills, and Attributes:
Effective collaborative and proven process improvement skills.
Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
Ability to work in a fast paced environment; ability to multitask.
Experience with standard Microsoft Office applications, particularly MS Outlook and MS Word, and other data entry processing applications.
Strong analytical and clinical problem solving skills.
Working Conditions and Physical Effort:
Regular and reliable attendance is an essential function of the position.
Fast Paced office environment
Work is normally performed in a typical interior/office work environment.
No or very limited physical effort required. No or very limited exposure to physical risk.
BMC HealthNet Plan is a non-profit managed care organizations committed to providing the highest quality healthcare coverage to underserved populations. In Massachusetts, BMC HealthNet Plan is the business name for Boston Medical Center Health Plan, Inc.; outside Massachusetts, Well Sense Health Plan is the business name.
BMC HealthNet Plan serves Massachusetts residents across four product lin...es: MassHealth (Medicaid), ConnectorCare, Qualified Health Plans, and Senior Care Options. We are one of the largest Medicaid health plans and the lowest cost Qualified Health Plan in 6 out of 7 regions* in Massachusetts.
We are committed to the communities we serve and we want to focus on the unique health needs and resources particular to those communities. That’s why BMC HealthNet Plan has its corporate office in Boston and teleworkers located throughout the state. In New Hampshire, Well Sense Health Plan’s office and staff are located in Manchester.
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