Hybrid Registered Nurse Care Manager - MLTC - 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 discharges 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

Education and Experience

• Associate's 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.

Licensure and Certification

• Current, unrestricted Registered Nurse licensure in the state of New York required.
• Case Management Certification preferred.
• Must have valid driver's license, vehicle and verifiable insurance.
• Employment conditional on successful clearance of a driver’s license record check.
• Influenza vaccination is a requirement of this position; annual proof required during Influenza season (October 1 – March 31).

Qualifications

• Intermediate proficiency level with Microsoft Office, including Outlook, Word and Excel.
• Ability to communicate effectively with a diverse group of individuals.
• Ability to multi-task and work independently