Clinical Care Manager, Rn

Overview

Provides telephonic clinical care management services using evidence-based practices to ensure effective utilization of benefits, services, and care is provided to the patients allowing them to remain safely in their home/community.

Responsibilities
• Coordinates and/or oversees the coordination of benefits and services for all members on his/her caseload. • Completes care management and disease specific assessments. • Makes timely telephonic care management calls based on risk level. • Resolves and coordinates complex issues and member complaints impacting the delivery of services. • Provides health education to member/caregiver. • Assess SDoH and provide care coordination to reduce/remove barriers of care to include ability to allow for changing levels of care based on assessments, trigger events and program data/reports. • Identifies member safety issues and intervenes as necessary or refers to appropriate resources, such as community linkages, dietary, therapy (PT/OT/ST), HHA services, behavioral health, and DME. • Coordinates the delivery of high quality, cost-effective care based on a customized population model of care supported by evidence based clinical practice guidelines. • Advocates for the member/caregiver to obtain the health care and other services needed to optimize their quality of life. • Utilizes the Care Management process to set priorities, plan, organize and implement interventions that are goal directed towards self-care outcomes and the transition to independent status. • Promotes adherence to the physician treatment plan by providing education, coaching and support. • Educates, coordinates, and provides resources to reduce inappropriate utilization of emergency room (ER) and hospital service. • Increases utilization of primary care, specialty care, preventive health and guideline-based treatments including proper pharmacotherapy within network, as appropriate. • Participates in interdisciplinary team (IDT) meetings and provide input on customer service-related activities. • Protects the confidentiality of member information and adheres to company policies regarding confidentiality. • Ensures compliance with payors’ policies and procedures as well as all Federal and State regulations. • Interprets and implements VNS Health policies, state and federal regulations. • Participates in special projects and performs other duties as assigned.
Qualifications
Licenses and Certifications:
License and current registration to practice as a Registered Professional Nurse in NYS required Population Care Coordination certification preferred Care Management, Case Management, OASIS or other applicable certification preferred

Education:
Associate's Degree in nursing required Bachelor's Degree in nursing preferred

Work Experience:
Minimum two years of experience as a registered nurse required Care management and/or managed care experience preferred Proficiency in Microsoft Office applications required Demonstrated analytical skills required