Job Summary
Provides support for care management/care coordination long-term services and supports (LTSS)-specific activities. Collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum for members with high-need potential. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care.
Essential Job Duties
- Completes comprehensive member assessments within regulated timelines, including in-person home visits as required.
- Facilitates comprehensive waiver enrollment and disenrollment processes.
- Develops and implements care plans, including a waiver service plan in collaboration with members, caregivers, physicians and/or other appropriate health care professionals and member support network to address the member needs and goals.
- Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly.
- Promotes integration of services for members including behavioral health care and long-term services and supports (LTSS) and home and community resources to enhance continuity of care.
- Assesses for medical necessity and authorizes all appropriate waiver services.
- Evaluates covered benefits and advises appropriately regarding funding sources.
- Facilitates interdisciplinary care team (ICT) meetings for approval or denial of services and informal ICT collaboration.
- Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.
- Assesses for barriers to care and provides care coordination and assistance to members to address psycho/social, financial, and medical obstacles concerns.
- Identifies critical incidents and develops prevention plans to assure member health and welfare.
- May provide consultation, resources and recommendations to peers as needed.
- Care manager RNs may be assigned complex member cases and medication regimens.
- Care manager RNs may conduct medication reconciliation as needed.
- 25-40% estimated local travel may be required (based upon state/contractual requirements).
Required Qualifications
- At least 2 years of experience in health care, including at least 1 year experience in care management, managed care, and/or experience in a medical or behavioral health setting, and at least 1 year of experience working with persons with disabilities, chronic conditions, substance abuse disorders, and long-term services and supports (LTSS), or equivalent combination of relevant education and experience.
- Registered Nurse (RN). License must be active and unrestricted in state of practice (NY).
- In some states, a bachelor's degree in a health care related field may be required (dependent upon state/contractual requirements).
- Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law.
- Ability to operate proactively and demonstrate detail-oriented work.
- Demonstrated knowledge of community resources.
- Ability to work within a variety of settings and adjust style as needed - working with diverse populations and various personalities and personal situations.
- Ability to work independently, with minimal supervision and demonstrate self-motivation.
- Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations.
- Ability to develop and maintain professional relationships.
- Time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.
- Problem-solving skills.
- Strong verbal and written communication skills.
- Microsoft Office suite/applicable software program(s) proficiency.
- In some states, must have at least one year of experience working directly with individuals with substance use disorders.
Preferred Qualifications
- Certified Case Manager (CCM)
- Experience working with populations that receive waiver services.
- Bilingual - Spanish, Cantonese or Mandarin
Pay Range: $26.41 - $61.79 / HOURLY