Advanced Practice Registered Nurses / Physician Assistants
The Complex Care Nurse Practitioner works with relevant stakeholders to identify and engage pediatric patients/families in care management with a focus on patient/family experience, improving health and reducing cost. The individual is responsible for working with patients/families to identify strengths and barriers and to develop an individualized, patient-centered care plan. The individual is responsible for direct patient care for patients requiring advanced practice intervention. Excellent interpersonal skills, patient engagement skills and the ability to work independently and collaboratively are key requirements of the job.
The NP will contact the family at least once every six months to monitor the child’s status, review family concerns, and assess the appropriateness of service utilization. S/he will also alert the child’s pediatrician and the Complex Care Pediatrician via secure email to any important new clinical information on the child and also note this information in the EMR and on the care plan.
S/he will arrange for case conferences as needed, involving the child’s school or day care and early intervention services providers as appropriate.
It will be critical for the NP to oversee transitions in care, particularly from hospital to home. To this end, s/he will maintain close contact with the attending physician and senior resident on the inpatient unit during any periods of hospitalization, consult with the Complex Care Pediatrician as appropriate; collaborate with the discharge nurse on post-acute care plans; and ensure a smooth transition from inpatient care back to the child’s pediatrician and the larger community.
Transitions between settings will trigger a review of the care plan by the NP.
1) Care Coordination and Management
Collaborates with other members of the health care team involved in patient care to provide a comprehensive approach to care for both inpatient and outpatients
Educates patients and their families on disease management.
Triages patient questions/concerns, refers to physicians for medical/surgical follow-up as indicated.
During clinical visits completes assessment of current health status, quality of life, side effects and vital signs.
Maintains clinical databases
Serves as liaison to healthcare professionals throughout the hospital.
2) Program Management
Triages patient concerns and queries
Prepares patient/family teaching material.
Maintains program contact list, including BMC staff, partnering hospitals, device companies and community services.
Reviews, verifies and retrieves data.
Acts as liaison between BMC and referring community health centers/PCPs.
Attends relevant conferences for continuing medical education
Travels and participates in investigator and program meetings.
Participates in community awareness and referring physical education
3) Conforms to hospital standards of performance and conduct, including those pertaining to patient rights, so that the best possible customer service and patient care may be provided.
4) Utilizes hospital’s Values and adheres to all of BMC’s RESPECT behavioral standards as the basis for decision-making and to facilitate the division’s hospital mission.
5) Follows established hospital infection control and safety procedures
6) Perform other duties as assigned or as needed.
A minimum of four years of clinical experience is required, with care management experience preferred; candidate should have demonstrated leadership and supervisory experience and potential.
Clinical experience working with patients with multiple complex health issues
Excellent interpersonal skills and ability to work collaboratively
Self-management skills, including ability to prioritize and set patient-centered goals
Excellent written and verbal communication
Able to maintain professional boundaries
Ability to work with diverse, safety-net population
Skilled at engaging difficult to engage patients—build rapport, trust
Creative problem solver
Ability to adapt to changes in healthcare delivery at local and systems level
Extensive knowledge of healthcare systems and community resources
Ability to leverage systems and resources for improved patient outcomes
Strong organizational and time management skills
Internal Number: 1234
About BMC HealthNet Plan
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 over 400,000 Massachusetts residents across four product lines: MassHealth (Medicaid), ConnectorCare, Qualified Health Plans, and Senior Care Options.