Clinical Care Manager-RN (MA)

WellSense Health Plan is a nonprofit health insurance company serving more than 680,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded more than 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances. It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. Job Summary The Clinical Care Manager provides holistic clinical care management services for members across the continuum of care through comprehensive assessment, care planning, education, care coordination, advocacy, and ongoing monitoring. The Clinical Care Manager works collaboratively with members, families, providers, community organizations, and multidisciplinary care teams to improve health outcomes, promote self-management, address barriers to care, and ensure appropriate utilization of healthcare services. The Clinical Care Manager supports diverse member populations, including individuals with chronic and complex medical conditions, behavioral health comorbidities, special health care needs, maternal-child health needs, newborns with complex medical conditions, high-risk and priority populations, individuals experiencing homelessness, and members requiring intensive care coordination across multiple systems of care. Utilizing telephonic outreach, virtual engagement, data analysis, and face-to-face visits, the Clinical Care Manager conducts assessments, develops individualized care plans, coordinates services, and promotes member engagement through evidence-based practices and motivational interviewing techniques. The role emphasizes whole-person care by integrating medical, behavioral health, psychosocial, socioeconomic, and community-based supports. Our Investment in You: Key Functions/Responsibilities Supports programs and clinical best practices with the objective of improving health outcomes, preventing hospital readmissions, improving member safety and reducing medical errors, and promoting health and wellness activities, where appropriate. Clinical Assessment and Care Planning Completes comprehensive assessments, medication reconciliations, targeted clinical assessments, and condition-specific evaluations to identify members' medical, behavioral, psychosocial, functional, and social determinants of health needs. Evaluate members for complex care management, disease management, chronic condition management, maternal-child health programs, and other specialized care management services. Collaboratively develop, implement, monitor, and update individualized care plans based on member goals, clinical needs, and available resources. Establish short-term and long-term goals that support improved clinical outcomes, self-management, and quality of life. Continuously evaluate the effectiveness of interventions and revise care plans as needed. Member Engagement and Education Utilize motivational interviewing and evidence-based engagement techniques to promote member participation in care management and support behavior change. Educate members and caregivers regarding disease processes, preventive care, treatment plans, medication adherence, and self-management strategies. Provide health education using culturally appropriate and health literacy-sensitive materials. Support members in understanding and navigating healthcare benefits, services, and available community resources. Promote member adherence to prescribed treatment plans and preventive health recommendations. Care Coordination and Population Management Coordinate services across the healthcare continuum, including primary care, specialty care, behavioral health, pharmacy, community services, and state agencies. Facilitate transitions of care through pre-admission assessments, discharge planning, medication reconciliation, appointment scheduling, and follow-up activities. Identify and address barriers to care, including transportation, housing, food insecurity, financial challenges, and other social determinants of health. Coordinate referrals to internal and external programs and resources, including but not limited to behavioral health, social care management, community health workers, home health services, durable medical equipment, and community-based organizations. Collaborate with providers, hospitals, facilities, community organizations, and state agencies to ensure coordinated, member-centered care. Maternal and Child Health Responsibilities Provide care management services to pregnant and postpartum members, infants, and pediatric members with complex healthcare needs. Coordinate prenatal, postpartum, pediatric, and specialty care appointments and services. Support members through pregnancy, delivery, postpartum recovery, newborn care, and pediatric health using evidence-based maternal-child health practices. Manage care for infants diagnosed with low birth weight, neonatal abstinence syndrome (NAS), neonatal opioid withdrawal syndrome (NOWS), and other medically complex conditions. Collaborate with families, providers, hospitals, child welfare agencies, and community resources to support safe and effective care planning. Promote timely prenatal care, postpartum care, immunizations, well-child visits, and developmental services. Behavioral Health Responsibilities Performs a variety of diverse and complex telephonic care management responsibilities and ensures all service needs are met through monitoring of treatment plans, crisis plans, and interagency collaboration. Supports member transitions from inpatient to post-acute or community settings via engagement with facilities and other transitional team members. As needed, identifies service delivery gaps and barriers, ensures appropriate evaluation, service planning, and service delivery, and monitors care plan implementation and progress. Works closely with state agency case management staff, particularly the Department of Mental Health and Community Mental Health Centers (CMHCs). In all activities works to ensure linkage and integration of behavioral health and medical. This includes both member-based activities and work with agencies as part of community-based care management. Documentation, Quality and Program Support Document assessments, medication reconciliations, interventions, care plans, outcomes, and member interactions within designated care management systems in accordance with organizational, contractual, regulatory, HIPAA, and accreditation requirements. Utilize clinical data, utilization reports, electronic medical records, and care management platforms to support decision-making and care coordination activities. Participate in interdisciplinary rounds, care conferences, team meetings, and clinical reviews Participate in quality improvement initiatives, program development, process improvement activities, and departmental projects. Assist with staff development, mentoring, and cross-functional collaboration activities as assigned. Assists with user acceptance testing as needed Maintain and apply knowledge of regulatory, contractual, and accreditation requirements. Qualifications Education Bachelor's degree in Nursing required; Or A master’s or doctoral degree in a behavioral health field such as psychology, clinical counseling, social work or psychiatric nursing required Associate Degree in Nursing with relevant experience may be considered. Certification or Conditions of Employment Must hold a current state licensure Current unrestricted Registered Nurse (RN) license in the state of employment required or Must hold a current certificate or state licensure o Massachusetts: RN (with experience in the behavioral health field), LICSW, LMHC, LMFT, LADC-1 (with additional licensure), Clinical Nurse Specialist or Licensed Psychologist. o New Hampshire: RN (with experience in the behavioral health field), LICSW, LCMHC, MLADC, LMFT, Clinical Nurse Specialist or Licensed Psychologist Experience Minimum three (3) years of clinical experience working with members who have chronic, complex, or high-risk health conditions. Two or more years related experience in Mental Health, BH Case Management, and/or substance abuse treatment Minimum two (2) years of experience in care management, care coordination, discharge planning, utilization management, or related healthcare settings. Experience working with Medicaid populations and community-based service systems preferred. Maternal-child health, pediatric, neonatal, Behavioral Health, home health, managed care, or population health experience preferred. Strong clinical assessment and care planning skills. Advanced motivational interviewing and member engagement skills. Excellent verbal and written communication abilities. Strong analytical, critical thinking, and clinical problem-solving skills. Ability to collaborate effectively with multidisciplinary teams and community partners. Strong organizational, time-management, prioritization, and documentation skills. Proficiency with Microsoft Office applications, electronic medical records, and care management software platforms. Working Conditions Work may be performed in a remote or community-based work environment. Frequent telephonic and electronic member engagement activities. Face-to-face visits may occur in member homes, provider offices, hospitals, shelters, community locations, and state agencies. Regular and reliable transportation required. Travel may be required based on member and program needs. Regular and reliable attendance is an essential function of the position. Compensation Range $69,500 - $101,000 This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing. Note This range is based on Boston-area data, and is subject to modification based on geographic location. About WellSense WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. WellSense is committed to the diversity and inclusion of staff and their members. 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. WellSense participates in the E‑Verify program to electronically verify the employment eligibility of newly hired employees. #J-18808-Ljbffr WellSense Health Plan