RN - Home Base Nurse Case Manager - MGH

Job Summary

Home Base, a Red Sox Foundation and Massachusetts General Hospital program, is dedicated to healing the invisible wounds 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.

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.

Essential Functions

• Establishes and maintains care coordination for recommendations and referrals arising from the COMBHAT Program.
• Facilitates patients' return to Home Base for additional treatment programs when recommended and collaborates 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.
• Client assessments and planning.
• Modifies patient treatment plans as indicated by patients' responses and conditions.
• Prepares patient/family for discharge.
• Communicates with third-party payers to obtain necessary authorization for reimbursement of services.
• Reviews 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.
• Maintains accurate, detailed reports and records.

Qualifications

Associate's Degree in Nursing required or Bachelor's Degree in Nursing preferred. This role does not accept experience in lieu of a degree.

Registered Nurse [RN - State License] required. Basic Life Support [BLS Certification] preferred.

Case management, utilization review, or discharge planning experience 2-3 years preferred.

Knowledge, Skills and Abilities

• Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
• Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
• Ability to establish strong rapport and relationships with patients and staff.
• Proficient in Microsoft Office and industry-related software programs.
• Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
• Ability to maintain client and staff confidentiality.
• Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
• Knowledge of Healthcare and Managed Care preferred.