Clinical Case Manager DE Long Term Services & Support RN | LCSW

Amerihealth Caritas•,

38d

About The Position

The Clinical Case Manager assists members eligible for Long Term Services and Supports (LTSS) in obtaining services required by DSHP Plus LTSS in New Castle County. The role contributes to case management through telephonic and face-to-face assessment, identification, evaluation, coordination, and management of members’ physical health, behavioral health, social service, and LTSS needs. The position completes annual or as-needed Level of Care Redeterminations for home and community-based members, including clinical review of continued program eligibility. It also provides clinical support to non-licensed case managers and may serve as a secondary case manager during an acute episode. The role coordinates care for medically complex LTSS members receiving private duty nursing, including follow-up on outstanding needs, PDN coverage calendar maintenance, communication with agencies and member representatives, and coordination of precertifications and Letters of Medical Necessity. The Clinical Case Manager works with provider network teams on non-contracted providers or facilities through the single case agreement process. The position conducts initial and ongoing clinical and comprehensive needs assessments, develops care plans, initiates services, facilitates person-centered planning meetings, and helps members access covered and non-covered services and supports. It monitors authorized services, provides condition-specific education and follow-up, explains LTSS assessments and service options, supports members with rights and grievance processes, and gathers member preferences, strengths, and goals for care planning. Additional duties include reviewing worklists in Jiva, authorizing urgent services, monitoring critical incident reporting, coordinating with physical health care coordination, and supporting LTSS and DSNP members with assessments, medication reconciliation, follow-up, and transitions of care. Duties may include case management responsibilities based on business needs, and a caseload may be assigned as part of the contingency plan when staffing needs arise.

Requirements

Delaware-licensed RN.
Ability to travel throughout the entire state of Delaware.
Valid driver’s license.
Knowledge of the home and community-based service system and how to access and arrange services.
Experience conducting LTSS needs assessments and monitoring LTSS delivery.
Ability to provide informed advocacy.
Ability to interact with members face to face.
Ability to interact professionally with health care professionals.
Ability to travel up to 75%.

Responsibilities

Assist LTSS-eligible members in obtaining services required by DSHP Plus LTSS in New Castle County.
Conduct telephonic and face-to-face assessments to identify, evaluate, coordinate, and manage members’ physical health, behavioral health, social service, and LTSS needs.
Complete annual or more frequent Level of Care Redeterminations, including clinical review of continued program eligibility.
Coordinate care for medically complex LTSS members receiving private duty nursing, follow up on outstanding needs, maintain a PDN coverage calendar, and communicate with PDN agencies and members or representatives.
Coordinate with the prior authorization team to submit precertifications and assist in obtaining Letters of Medical Necessity as needed.
Coordinate with the provider network team on non-contracted providers or facilities through the single case agreement process.
Provide clinical support to non-licensed case managers and serve as a secondary case manager when a member experiences an acute episode.
Conduct condition-specific assessments for members with chronic conditions and provide education and routine follow-up.
Perform initial clinical assessments for new members, develop care plans, and initiate services.
Facilitate person-centered planning team meetings and help participants access LTSS, covered services, and other medical, social, housing, educational, and support services.
Provide information to participants and monitor authorized services and supports.
Explain available LTSS needs assessments, the care plan process, service alternatives, and service delivery options.
Inform participants of their rights and responsibilities and assist with complaints, grievances, and the DHS Fair Hearing process.
Collect participant preferences, strengths, goals, and other information to support Plan of Care development.
Conduct comprehensive needs assessments annually or more frequently as required.
Review and act on Jiva worklists, including monitoring new members.
Authorize urgent services when needed.
Monitor critical incident reporting and documentation and recommend or take action with other corporate entities as required.
Perform liaison activities with the Physical Health Care Coordination program.
Work with LTSS and DSNP members on comprehensive assessments, care plans, medication reconciliation, monitoring follow-up and progress, and discharge planning and transitions of care.
Travel throughout Delaware and, as business needs require, take on case management duties or a caseload under the contingency plan.