Nurse Care Manager

CareSource

About The Position

Job Summary: 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. Essential Functions: 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

Associates degree in Nursing from an accredited nursing program required
Three (3) years of experience as a registered nurse required
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 within a team environment
Knowledge of local, state & federal healthcare laws and regulations & all company policies regarding case management practices
Adhere to code of ethics that aligns with professional practice
Knowledge of and adherence to Case Management Society of America (CMSA) standards for case management practice
Strong advocate for members at all levels of care
Strong understanding and sensitivity of all cultures and demographic diversity
Ability to interpret and implement current research findings
Awareness of community & state support resources
Critical listening and thinking skills
Decision making and problem-solving skills
Strong organizational and time management skills
Current, unrestricted Registered Nurse licensure in the state of New York required

Nice To Haves

Bachelor's degree in Nursing preferred
Clinical experience in geriatrics and/or managed long-term care experience preferred
Experience using multiple languages may be required based on operational needs
Bilingual speaking and writing skills are preferred
Case Management Certification preferred

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.