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One Care Program Manager

4 months ago


Boston, United States Boston Health Care for the Homeless Program Full time
Job DescriptionJob Description

Who We Are:
Since 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 10,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Our clinicians, case managers, and behavioral health professionals work in more than 30 locations to serve some of our community’s most vulnerable—and most resilient—citizens.

From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all. We provide community-based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face.

Bilingual, Bicultural, LGBTQIA identifying, Black, Indigenous, and People of Color are encouraged to apply.

To learn more about working at BHCHP, watch our video Please Click Here.

Job Summary:
***NOW OFFERING A $4,000 SIGN ON BONUS***
Hours:  Full time, Monday - Friday, 8:30am-5:00pm

As the Program Manager you will be responsible for providing clinical and administrative leadership to BHCHP’s OneCare team while still maintaining direct nurse care management responsibilities.  You will collaborate with the OneCare Program Director and Medical Director to identify strategic program needs including setting and obtaining annual goals, developing onboarding and ongoing training programs for staff, engaging medical providers in helping OneCare patients achieve their goals, and supporting population health strategies including quality improvement initiatives. In addition, you will represent BHCHP’s OneCare program and advocate for our patients at various Commonwealth Care Alliance (CCA) meetings in Massachusetts including leadership and clinical meetings.  The OneCare program is a federal- state insurance benefit administered by CCA to promote care coordination, continuity of care, and improved health outcomes for those patients between 21- 65 years of age who are eligible for both Medicare and Medicaid. 

In this role, you will also be required to connect with patients who are enrolled in the One Care Program and perform an initial Minimum Data Set (MDS) assessment and create a care plan for all BHCHP patients participating in the OneCare program.  OneCare RNs are responsible for updating assessments and care plans annually and when a patient has a significant change in status. This includes assisting care teams in collaborating with the OneCare Program to develop a comprehensive service delivery plan customized to meet the needs of the patient.   Patients can be housed; living in shelters or on the streets and RNs will need to be resourceful in building relationships with our patients. Strong and regular communication with BHCHP care teams, other medical and social providers, and shelter partners; the use of BHCHP and CCA electronic medical records; and face to face outreach to patients who are living on the street are all required elements of this position.  You will need to remain flexible and creative as this role will continue to expand and evolve as experience is gained with continued participation in the One Care Program.
Responsibilities:

  • Responsible for working with the Program Director to hire and onboard new staff and ongoing training as needed; works with team to develop workflows to help meet program standards.
  • Supervises team of OneCare Registered Nurses and Team Coordinator and oversees regular team meetings; provides clinical oversight to care coordinator team and RNs for their assigned patient panel.
  • Collaborates with OneCare Medical Director and Program Director and other staff to focus on quality initiatives and support clinical competence; consults with Managed Care Organization (Commonwealth Care Alliance) on the medical needs of enrollees and required program elements monthly and as needed. Attends leadership meetings organized by CCA for Health Homes.
  • Engages a select panel of patients and provides complex care management, supports transitions of care, and supports medication reconciliation and advancement of patient goals; coordinates care between BHCHP care teams and the OneCare Program for the BHCHP patients who are enrolled in the OneCare Program.
  • Collaboratively participates as a member of the primary care team that includes M.D.s, N.P./P.A.s RNs, Behavioral Health clinicians, Medical Assistants, Case Managers and others.
  • Uses OneCare’s and BHCHP’s Electronic Medical Records (EMR) in a timely manner to note all patient interactions and outcomes accurately and efficiently. (OneCare uses two EMRs).
  • Communicates clearly and professionally with other members of the interdisciplinary team as well as with patients and caregivers. Represents OneCare program at clinician/provider meetings as needed.
  • Maintains and updates tracking records. Identifies high risk patients for outreach.
  • Conforms to BHCHP standards of performance around patient rights, customer service, infection control, safety procedures and culturally competent care.
  • Remains flexible in duties as role expands and is available for assistance with other projects as needed.
Qualifications and skills:
  • License Registered Nurse with the Commonwealth of Massachusetts; 5 years nursing experience with complex patients
  • Experience leading quality improvement initiatives. Experience and strong interest in population health management using data to help improve care.
  • Experience working with vulnerable populations, including persons with a history of trauma, those experiencing socioeconomic stress, homelessness, or substance use disorders.
  • Strong interpersonal skills and clinical problem solving; supervision experience a plus.
  • Comfort working in an autonomous clinical setting and nursing in an outreach setting.
  • Bilingual skills in Spanish and English preferred.
  • Computer skills:  Proficient with Microsoft Excel Spreadsheets, entering narrative and other data into a database, Epic HER; flexibility and strong multitasking skills.
Compensation and Benefits
***NOW OFFERING A $4,000 SIGN ON BONUS***
  • The compensation starts at $42.60, and increases based on years of experience.
  • BHCHP full time employees are eligible for our competitive time off policy of 4 weeks’ vacation, health, dental and vision insurance, 403B retirement savings plan and employer retirement contribution, and pre-tax MBTA pass program with 40% discount. In addition, eligible employees will receive yearly increases, additional compensation of seven thousand five hundred added to your base hiring rate for demonstrated bilingual proficiency and the opportunity to work with local hospitals and community health centers.

Does this amazing opportunity interest you? Then we'd love to hear from you.

As an Equal Opportunity Employer, BHCHP pledges not to discriminate against and encourages those from underrepresented and underserved backgrounds to apply, particularly Black, Indigenous, and People of Color (BIPOC), LGBTQIA identifying, first generation college students and adults without a college degree, Bilingual and Bicultural persons; and individuals from low economic backgrounds.

Covid-19 Vaccination: Proof of Covid-19 vaccination(s) is optional for employment. Candidates who are offered employment will be given details about how to demonstrate receipt of vaccination if they choose to.

Please Note: Employment at Boston Health Care for the Homeless is at-will. Boston Health Care for the Homeless does not sponsor work authorization visas.

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