Job Description

GENERAL SUMMARY/ OVERVIEW STATEMENT: The Red Sox Foundation and Massachusetts General Hospital Home Base Program is an innovative public/private partnership dedicated to improving the lives of service members, veterans, and their families who have served in support of all conflicts and live with service-related or combat-related stress and/or traumatic brain injury. Home Base provides clinical care and support services, as well as community education and innovative research. A combination of individualized, high quality assessment, consultation, treatment, and rehabilitation services are provided at the Home Base Veteran and Family Outpatient Clinic and our 14-day Intensive Clinical Program. In addition, Home Base serves as a leader in research, identifying and implementing new treatments for post traumatic stress disorder (PTSD) and traumatic brain injury (TBI) and other service-related mental health challenges.

The Massachusetts General Hospital seeks a dynamic and experienced professional to provide Nurse Case Management services for the Red Sox Foundation and Massachusetts General Hospital Home Base Program Traumatic Brain Injury patients, with special emphasis on the Intensive Clinical Program (ICP). Veterans treated in the ICP will be referred to Home Base from locations nationwide; the care coordination will include local as well as national relationships and management of follow-up care. Under general supervision of the Senior Clinical Director, the Medical Director, and Nurse Manager of the Home Base Program, the Home Base ICP Nurse Case Manager will ensure that Home Base patients are seen in a timely manner by the appropriate clinician(s) within the Home Base Program, and that appropriate communication and coordination of care is maintained with referring physicians inside of MGH and outside in the community. She/he will also serve as a dedicated relationship manager and liaison between the Home Base providers, the referring and referred to clinicians, patients and their families. This individual is responsible to reach out to community physicians, other specialists, and to patients and their families, to educate them about the Home Base program and services. The goal of this position is to ensure appropriate coordination of care is established and referrals are processed as needed and as directed by the clinical staff of the Home Base program in order to grow the Home Base programs volume and to ensure exemplary customer service for patients and their families.

PRINCIPAL DUTIES AND RESPONSIBILITIES:
Facilitating Access: Working closely with the Red Sox Foundation and Massachusetts General Hospital Home Base Program leadership, clinicians, and administrative staffs, the Home Base Program Nurse Case Manager is responsible for coordinating care to the appropriate internal or external clinicians
Manages the coordination of care for Home Base patients with a special focus on TBI ICP patients in need of care and/or services from physicians, the VA system, other agencies from regional, national, and international communities as needed.
Assist in triage of medical urgencies/emergencies
Serves as central contact point for accepting and triaging referrals from outside clinicians and self-referred patients.
Collects all preliminary information necessary to direct the referral to the appropriate clinician.
Coordinates appointments with appropriate Home Base clinician(s) as well as assisting patients to navigate referrals within the MGH system during their time in the ICP. Notifies referring physician of the specifics of the referral that has been made.
Ensures timely access for patients into the Home Base Program. Explore innovative ways to increase access.
Communicates patient and family needs to appropriate clinicians.
Occasional weekend effort
Maintains familiarity with the activities and interests of the Home Base clinicians, MGH, and Spaulding Rehabilitation Hospital in order to provide the most appropriate coordination of care and triage into the Home Base Program.
Promotes direct and timely access and problem solving for urgent clinical situations.
Identifies and helps to resolve service delivery problems; recommends methods to improve and streamline services.
Works with the Home Base program clinicians, support staff, and administrators, to establish processes for prompt resolution of complaints.
Relationship Management: Is responsible for developing and maintaining relationships with new and existing referring physicians, behavioral health clinicians, clinical and support staff, patients and families. Serves as a liaison for the patient and their family between clinicians, administration, and the community.
Educates patient and family regarding visit, procedures, treatments, results and any other pertinent information.
Identifies and monitors relationship histories, including details of prior referrals from referral sources, and referrers preferred communication methods, by developing and maintaining a relationship-management database.
Routinely communicates with referring clinicians to establish effective networking.
Identifies and summarizes referring physician/center/clinician needs to the Home Base leadership.
Collaborates with Home Base clinicians and leadership to develop and implement standards for communication with referring physicians/centers/clinicians.
Follows-up on all requests to ensure a high level of customer satisfaction for patients, their families, and referring physicians.
Outreach/Education/Promotion: In collaboration with Home Base Program leadership, assists in developing and implementing clinical marketing/outreach efforts and programs for community, patient, and referring physician/center/clinician education.
Attends appropriate Home Base, and military, related events to meet new potential referring physicians.
Meets with existing and potential referring physicians to communicate and promote the Home Base Programs mission, services, and strengths and to identify benefits to physicians and patients.
Participates/displays/represents the programs at appropriate local and national conferences/forums as requested.

* RN License

* Minimum of 3 years inpatient/outpatient medical/surgical nursing experience. Record review, telephone triage, Phlebotomy and IV Insertion experience a plus.
Massachusetts General Hospital is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. Applications from protected veterans and individuals with disabilities are strongly encouraged.
EEO Statement
Massachusetts General Hospital is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. Applications from protected veterans and individuals with disabilities are strongly encouraged