RN - Home Base Nurse Case Manager - MGH

Job Summary

Onsite every Thursday and Friday, with additional onsite work as needed to support program operations. Home Base, a Red Sox Foundation and Massachusetts General Hospital program, is dedicated to healing the invisible wounds – including post-traumatic stress, traumatic brain injury, anxiety, depression, co-occurring substance use disorder, family relationship challenges and other issues associated with Military service – for Veterans of all eras, Service Members, Military Families and Families of the Fallen through world-class clinical care, wellness, education, and research.

The Massachusetts General Hospital seeks a dynamic and experienced professional to provide Nurse Case Management services to COMBHAT patients at the Red Sox Foundation and Massachusetts General Hospital Home Base Program. Veterans and Active-Duty Service Members treated in the COMBHAT Program are referred to Home Base from locations nationwide, including directly from military commands.

Under the general supervision of the Associate Director of Brain Health and the Brain Health Nurse Team Lead, the Home Base COMBHAT Nurse Case Manager will serve as the primary relationship liaison among Home Base providers, patients, families, military commands, and referral sources in patients’ local communities and across the MGB network.

• Establishes and maintain care coordination for recommendations and referrals arising from the COMBHAT Program.
• Facilitate patients’ return to Home Base for additional treatment programs when recommended and collaborate closely with the Brain Health Resource Specialist to identify local resources that support treatment completion.

Serves as a core member of the care team, coordinates and supports healthcare within the facility, and coordinates referrals for services outside the clinic. Provides outreach and enrollment services to meet the program's eligibility requirements and those of the surrounding counties. Ensures coordination and planning, including community and family support. Focuses on the development and coordination of community service plans. Partners with service providers, families, and patients to create a plan of healthcare and identify additional service providers.

Essential Functions

• Client Assessments and Planning.
• Modify patient treatment plans as indicated by patients' responses and conditions.
• Prepare patient/family for discharge.
• Communicates with third-party payers to obtain necessary authorization for reimbursement of services.
• Review cases with medical directors as needed to discuss challenging cases.
• Defines care goals of patients by providing education, information, and direction to each individual and family.
• Maintain accurate, detailed reports and records.
• Communicates with third-party payers to obtain necessary authorization for reimbursement of services.