RN Care Manager - Occasional - Days

Job Summary The Care Manager is responsible for completing a comprehensive assessment to determine the correct services and benefits based on medical necessity for an enrollee.

Provides plan education, transition of enrollees to clinical services based on Department of Health (DOH) guidelines.

Care management providing advocacy, coordination and oversight of all healthcare services for an enrollee striving to deliver the best care at the right time and in the most-cost effective while meeting quality outcome standards for the enrollee case load assigned.

Complies with all state and federal regulations including Health Insurance Portability and Accountability Act (HIPAA).

Core Job Responsibilities Identifies and coordinates enrollee services as provided by the plan and services that are not a benefit of the plan (Medicare Services).

Completes comprehensive assessment using the DOH approved tool to determine eligibility of medically necessary services.

Educates and completes with enrollee all necessary consents and documentation.

Initiates and carries out continuous assessment of physical, emotional, social, cultural, economic, and environmental needs of the enrollee and coordinates services for needs as determined.

Observes the enrollee for changes in condition and follows up with appropriate services or providers to attempt to prevent disease exacerbations.

Develops, monitors and revises a Plan of Care with the enrollee or enrollee’s designee that has problem, enrollee centered goals and interventions.

Implements orders for Durable Medical Equipment items and treatments as prescribed by the physician, submitting and maintaining appropriate medical orders and documentation.

Completes documentation per company standards/policy utilizing an Electronic Medical Record (EMR) system.

Participates in Marketing Activities as requested by Executive Director or Designee.

Accepts assignments and performs duties within their nursing scope of practice, seeking and obtaining sufficient information/education necessary to function effectively in the managed long term care setting.

Participates in departmental and organizational committees and meetings as applicable.

Participates in the orientation of new staff, mentors peers, and promotes collaborative teamwork.

Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with the basic principles of professional nursing.

Maintains a working knowledge of, and adheres to applicable federal/state regulations including, but not limited to, patient confidentiality, release of information, and HIPAA.

Performs other related duties as requested by the Executive Director or Clinical Services Manager.

Clarifies issues and actively addresses concerns in a timely manner.

Ability to manage conflict, stress, and multiple simultaneous work demands in an effective, professional manner.

Ability and willingness to self-motivate, prioritize, and be willing to change processes to improve effectiveness efficiency.

Adapts to changing enrollee or organizational priorities.

Ability to make independent decisions in accordance with established policies and procedures.

Performs related duties as assigned.