Hybrid Registered Nurse Care Manager - Bronx

About the role

The Nurse Care Manager is responsible for providing care coordination including in-home assessment, planning, facilitation, advocacy and authorization of covered plan services to meet the member's health needs while promoting quality cost effective outcomes.

Responsibilities

• Ensures consistent care along the entire health care continuum by assessing and closely monitoring members’ needs and status.
• Authorizes covered services and coordinates care regardless of payer.
• Collaborates and communicates with member/family/caregivers, primary care practitioners, and the interdisciplinary team.
• Works with member/family to maintain the most independent living situation possible.
• Assesses, plans and provides continuous care management across all venues of care, including hospital, sub-acute, long-term and home settings.
• Regularly assesses members for ongoing eligibility for services based on the specific plan’s eligibility criteria.
• Performs home visits as required to assess members’ living situation, cultural influences, functional and cognitive needs.
• Collaborates with the primary care physician and Inter-Disciplinary Team (IDT) to develop the Patient Centered Service Plan for the member.
• Ensures appropriate, safe plan for members’ discharge from their plan.
• Identifies same day grievances, investigates and documents accordingly; documents any grievance according to plan policy.
• Identifies and presents members with complex care management needs or in difficult to manage situations at Intensive Care management meetings (ICM).
• Responds to members’ requests in the designated timeframes and completes Initial Adverse Determinations (IAD) as indicated.
• Identifies members requiring Care Management Review (CMR), evaluates documentation provided by the IDT including hospital or nursing home discharge planners, and formulates appropriate plan of care.
• Documents care management/coordination according to company policy to the specific plan the member is enrolled in, which may include monthly telephonic and in person recertification notes.
• Develops efficient plans of care, authorizing only needed services at the most appropriate levels, utilizing network providers and ensuring that services are based on members’ needs.
• Perform any other job related duties as requested.

Requirements

Associates degree in Nursing from an accredited nursing program required; Bachelor's degree in Nursing preferred. Two (2) years of experience as a registered nurse required. Clinical experience in geriatrics and/or managed long-term care experience preferred. Experience using multiple languages may be required based on operational needs.

Current, unrestricted Registered Nurse licensure in the state of New York required. Case Management Certification preferred. Must have a valid driver's license, vehicle, and verifiable insurance. Employment is conditional upon successful clearance of a driver’s license record check; unacceptable results will withdraw the offer or terminate employment. Influenza vaccination is a requirement of this position; annual proof of vaccination is required during Influenza