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.
Education and Experience
- Associates degree in Nursing from an accredited nursing program required
- Bachelor's degree in Nursing preferred
- Three (3) years of experience as a registered nurse required
- Clinical experience in geriatrics and/or managed long-term care experience preferred
- Experience using multiple languages may be required based on operational needs
Competencies, Knowledge and Skills
- 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
- Bilingual speaking and writing skills are preferred
Licensure and Certification
- Current, unrestricted Registered Nurse licensure in the state of New York required
- Case Management Certification preferred
Working Conditions
- General office environment; may be required to sit or stand for extended periods of time
- Up to 25% (regular) travel may be required to travel to different locations, including homes, offices, or other public settings, to perform work duties
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.