RN GERIATRIC CASE MANAGER

Guided by the needs of our patients and their families, Massachusetts General Hospital aims to deliver the very best health care in a safe, compassionate environment; to advance that care through innovative research and education; and, to improve the health and well-being of the diverse communities we serve.

The PRIMECARE Nurse Care Manager is a member of a department providing fee-for-service geriatric care management services to elders and those who care for them.

* Perform comprehensive and targeted geriatric care management and “informal” caregiver assessments in a variety of settings. * Analyze assessment issues and findings, research good quality, cost effective strategies and solutions. * Develop a comprehensive written geriatric care management “action plan” based upon the elder’s safety, well being, goals and with consideration of the caregiver’s needs and goals. * Provide concrete methodologies and recommendations for successful implementation of the action plan. * Provide “action plan” implementation services which may include: * care coordination to support delivery of medical, psychosocial care and associated care plans, activities of daily living, legal, financial management, etc. * education regarding the health care delivery and reimbursement systems, prescription drug cost management, health & wellness programs, long term care insurance, health care proxy, asset and legal management, government, community agencies, public & private organizations, hiring through private entities, etc. * advocacy, to include writing appeals, to ensure the elder’s safety, physical, legal & financial well-being, to support their caregiving & quality of life goals, navigate the healthcare delivery system, obtain third party reimbursement for covered goods and services, etc. * assessment and monitoring of care being delivered to the elder and provision of recommendations to the elder and/or their representative regarding the advisability of the need to modify care, the care plan, providers and/or vendors, as necessary and appropriate * consultation and/or conferencing with the elder & their formal, informal caregivers, family, significant others, representatives to assess issues, consolidate information, coordinate planning and care delivery with and for the elder * assistance with selection and transitioning the elder from one environment to another * Communication with the elder, their representative and/or providers to effectively implement plans and provide updates regarding ongoing eldercare care management issues and services. * Practice and documentation of care management services per PRIMECARE professional standards of practice. * Effective management of professional service billing. * Patient Population Served: * The staff member must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served on his/her assigned unit. * Senior Adult (55 to 64 yrs) * Geriatric (65 yrs and up)

* Strong assessment and problem solving skills. * Strong interpersonal skills. * Ability to work independently with minimal supervision. * Goal oriented and accountable. * Demonstrated organizational and time management skills, including ability to flex schedule to meet client & business need. * Strong oral and written communication skills. * Interest and ability in small business operation and development * Registered Nurse with current MA license * Minimum of 5 years work experience, 2 of which must be related * Current Massachusetts Driver’s License and ability to travel to client location/s