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Nurse Case Manager, ACO

Job ID 85304 Full / Part Time: Full-Time
Location: Springfield, Massachusetts
Regular/Temporary: Regular


The Outpatient Nurse Care Manager is responsible for the management of care for a defined group of patients including complex care management, disease management, transitions of care, as well as coordination of care.  Major responsibilities include accurately identifying patients for care management, developing individualized plans of care, assessing/addressing barriers to care, medication reconciliation, medication titration as well as ensuring adherence to quality measures.  The goal is to work with patients to optimize control of chronic conditions, improve functional status, reinforce self-management plan and prevent/minimize long-term complications as well as to avoid unnecessary emergency room visits or hospital admissions. They will work collaboratively with physicians and other health team members along the patients continuum of care, and are available to patients and families for care coordination/education through face to face visits, home visits if necessary, as well as telephonic interactions. In addition, they will assist with advance directives, palliative care, hospice, and other end-of-life care coordination.  Appropriate documentation in patient medical records and/or care management application is required and is vital.  Care management program metrics including total medical expenses, emergency room utilization, and hospital admission/readmission data will be reviewed on a regular basis to measure program impact.

  • Coordinates, oversees and directs the interdisciplinary team members to provide care that is safe, timely, effective, efficient, equitable, and client-centered to the assigned patient population.
  • Responsible for appropriately identifying patients for care management utilizing multiple sources including physician referrals, referrals from transitions of care, health plans as well as complex lists of patients from the ACO.
  • Conducts whole person assessments to determine individual patient needs and create individualized self-management plans of care in conjunction with the patient/family.  Evaluate the effectiveness of the plan of care and revise as necessary to meet goals.
  • Manages transitions of care for patients discharged from the hospital, emergency room, or from a skilled nursing facility.  Responsible to review the discharge summaries, follow up on testing that is pending; ensure ordered services are in place.  Outreaching to the patients to perform medication reconciliation, ensure patients understanding of discharge instructions and assess for further care management needs.
  • Overseeing population management activities with the Care Coordinators which includes addressing quality indicators that are out of range and assisting patients to reach targets.


  • Bachelor’s Degree in Nursing, MA license and CPR
  • Master’s Degree preferred, MSN,  Clinical Nurse Leader (CNL) or Public Health
  • Minimum of 5 years’ experience as a Registered Nurse and  a minimum of 2 to 3 years of population health and/or healthcare experience
  • Strong communication, interpersonal and problem solving skills to advocate for optimal patient outcomes.  Capacity to work closely with patients, physicians and their office staffs and managed care plans.  Strong organizational and prioritization skills.  Attention to detail and able to perform work independently. 
  • Bilingual skills preferred. 
  • Driver’s License Required

Other Information

  • Full Time 40 hours Monday - Friday 
  • Resume Required

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

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