RN Care Manager

Responsibilities

• Assists members with obtaining needed medical, social, educational, psychosocial, financial, and other services.
• Partners with a Social Worker to facilitate the MLTC care model by coordinating services and community resources and meeting the members socioeconomic needs to support the quality of life.
• Provides a care management process of assessment, planning, facilitation, and advocacy for options and services to meet a member’s home health needs through collaboration, communication, and available resources, while promoting quality cost-effective outcomes.
• Develops and maintains a person-centered service plan based on a needs' assessment identifying the strengths, capacities, preferences and long-term goals of the Member, resources available to meet member needs and ongoing revisions to the service plan based on the changes in the Member’s condition and status.
• Participates in the utilization review process and evaluates to determine if the member’s condition and needs meet criteria for covered services and provide service prior authorization or denials to health care providers.
• Reviews financial, legal, or medical issues and refers Members to social work or other professionals for estate planning, living wills, family trust, crisis services, and other programs.
• Ensures that documentation in the care management record meets all applicable professional standards, using an EMR for each observation, verbal report, or interaction with the Member, Member’s caregiver/family, PCP or other provider, whether by home visit, telephonic, or written interaction.
• Early identifies incipient problems or significant changes in Member conditions to initiate early intervention and strategies to prevent or more quickly treat chronic care exacerbations.
• Participates in Disease Management, Utilization Management, and Quality Improvement activities.
• Competently uses the UAS-NY assessment tool. Previous UAS-NY is desired, but not required. Training is available.

Qualifications

• BSN, AAS Degree or diploma in Nursing and Case Management Certification is preferred.
• A current New York State Registered Nurse License (Required).
• A valid NYS Driver’s license (Required).
• Minimum of three (3) years nursing experience in home care, case management, discharge planning or managed care.
• Minimum of one (1) year experience working with a frail or elderly population.
• Minimum one year experience with health assessments.
• Ability to focus on specific disease processes/health issues and identify strategies to promote client focused care planning.
• Familiarity with provisions of governmental and accrediting agency health plan requirements. Familiar with applying clinical criteria when determining medical necessity and/or benefit administration.

Additional Requirements

• Must have a safe driving record. A DMV motor vehicle report will be reviewed.
• Must be in good standing with the Medicare and Medicaid programs. This includes a criminal background check.
• Possess good speaking and listening skills.
• Bilingual skills (preferred).
• Must be free of communicable disease.