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
Compensation Range:
$100,000 - $160,000
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.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
