Hybrid Registered Nurse Care Manager - Queens

CareSource Management Services•New York City, NY

9d•Hybrid

About The Position

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. This role involves assessing and monitoring members' needs, authorizing covered services, and coordinating care across the healthcare continuum. The Nurse Care Manager collaborates with members, families, caregivers, primary care practitioners, and the interdisciplinary team to ensure members maintain the most independent living situation possible. They develop and implement patient-centered service plans, assess ongoing eligibility for services, and perform home visits to evaluate living situations and needs. The position also requires identifying and documenting grievances, presenting complex cases at intensive care management meetings, and responding to member requests within designated timeframes. Documentation of care management and coordination is crucial, adhering to company policies and specific plan requirements. The role involves developing efficient plans of care, authorizing necessary services at appropriate levels, and utilizing network providers.

Requirements

Associates degree in Nursing from an accredited nursing program required.
Three (3) years or 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 state of New York required.

Nice To Haves

Bachelor's degree in Nursing preferred.
Clinical experience in geriatrics and/or managed long-term care 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.