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Transition to Home Clinician

BMC HealthNet Plan

Transition to Home Clinician

2 locations
Charlestown, MA
Boston, MA
  • Responsibilities

    In this role, the Care Manager, Transitions of Care, Senior Care Options (SCO) will perform a variety of diverse and complex telephonic and face-to-face care management responsibilities as SCO Members transition through the continuum of care settings of the emergency department, acute inpatient and post-acute rehab/skilled nursing/nursing facilities and to the community setting. The primary focus of the CM for Transitions of Care is to ensure that the member experiences a seamless transition to the most appropriate level of care possible and to mitigate unnecessary emergency room and readmission utilization. The Care Manager will act as the medical clinician link within the Primary Care Team (PCT) in partnership with the Member, the Geriatric Supports Services Coordinator (GSSC), Behavioral Health, non-clinicians, pharmacists, inpatient utilization management staff, medical directors and others, as Members access care through the continuum.


    • Serves as the lead and advocate in the transition process ensuring continuity of care for the Member across all health care settings and back to the community
    • Uses daily census, EMR, and prior authorization reports to identify members in transitional care (inpatient, observation, ED)
    • Outreaches to Members and facilities prior to, during, and after transitions occur and educates and ensures compliance with post discharge regimens, improve self and ongoing management and medication reconciliation
    • Completes pre-admission and admission assessments and reports outcome of assessments and potential discharge plan to PCT
    • Coordinates a home safety visit prior to admission, as appropriate
    • Ensures notification to the PCT of Member’s admission and ED encounters occurs within 24 hours, of admission and ED notification receipt
    • Collaborates with the Member, appointed representative / caregiver, facility case managers, social workers, and discharge planners, and the PCT throughout the admission stay and for each transition to arrange a safe discharge plan as agreed upon by the Member and PCT
    • Ensures the MDS-3.0 assessments are completed timely and in compliance with the SCO Model of Care, contractual and regulatory requirements
    • Completes face to face MDS-HC assessments in a variety of care settings to include, but not limited to, acute inpatient, provider settings and community
    • Identifies Members who may be appropriate for a MDS-HC reassessment due to change in condition
    • Develops a person-centered IPC in collaboration with the Member and the PCT
    • Facilitates meetings of the PCT and communicates with the PCT on an ongoing basis ensuring essential clinical or psychosocial information related to the Enrollee’s care is shared across the PCT
    • Reviews and documents in the facility Electronic Medical Record, where available
    • Participates in team/family meetings and discharge planning activities through all care levels either telephonically or in-person
    • Meets with the Member as needed
    • Coordinates care necessary after discharge
    • Researches all aspects of Member care to understand member needs
    • Establishes a strong professional, trusting, and working relationship with facilities, Aging Services Access Points (ASAPS)/GSSCs, homecare agencies, throughout the SCO provider network
    • Works with SCO provider network on performance improvement projects relative to care transitions and utilization.
    • Evaluates the effectiveness of alternative care services and ensures that cost effective, quality care is maintained
    • Documents clinical assessments, IPCs, and coordination of care in the medical management information system.
    • Provides culturally competent care coordination in keeping with the Enrollee’s racial, ethnic and sexual orientation
    • Reviews and facilitates sharing of essential clinical and psychosocial data to ensure that clinical interventions result in improved clinical outcomes and appropriate utilization of services at the right time, right place, and right setting
    • Maintains HIPAA standards and confidentiality of protected health information.
    • Reports critical incidents and information regarding quality of care issues
    • Serves and participates in pertinent committees and meetings, as needed
    • Must become strongly knowledgeable in the full contractual requirements of the SCO Care Management agreements the SCO Model of Care and contracts with vendors and agencies
    • Participate in weekly BMCHP multidisciplinary rounds and present cases, as necessary
    • Additional responsibilities as needed



    • Registered nurse
    • Bachelor’s degree or an equivalent combination of education, training and experience is required


    • 2 years’ experience in Medical Case Management working with the geriatric population
    • Experience with the Medicaid, Medicare, and Senior population


    • Geriatric care management or nursing experience in a post-acute facility desired
    • Experience with ASAPs preferred


    • Valid applicable current state licensure as a Registered Nurse
    • Certification in case management (CCM)


    • Excellent clinical and assessment skills
    • Ability to work collaboratively and build strong relationships with providers, Members, and the PCT
    • Excellent working knowledge of Windows and Microsoft Office products
    • Flexible, independent, self starter with an ability to thrive in a fast paced environment
    • Commitment to quality
    • Projects positive, team oriented demeanor
    • Strong interpersonal skills including effective listening and ability to support, motivate and guide others
    • Strong oral and written communication skills
    • Strong organization and time management skills
    • Ability to successfully plan, organize and manage within a person centered integrated care team
    • Detail oriented
    • Ability to use a laptop, or tablet for documentation in the field


    • Work is normally performed in an office/home office and in the field at inpatient facilities with visits to member homes, as needed
    • On-call work required on a rotating schedule
    • Attendance and participation at BMCHP in-office meetings required
    • Attendance and participation at PCT meetings required and may include morning or evening meetings
    • Travel within the SCO geographic network required

    *Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

    Required Skills Required Experience

  • Locations
    Charlestown, MA • Boston, MA