Senior Care Manager - Transition of Care

Title: Senior Care Manager (Transition of Care)

Location: Remote- NE

Duration: 5 months.

Schedule: Must be available in the evenings during the week (flexible hours between 2pm-8pm) and on weekends (flexible hours with start time no earlier than 9am)

Approved for up to 40 hours. Would like at least 20 hours a week with opportunity to increase hours with fluctuation in need.

Pay Rate: $38/hr. - $44.00/hr..

Job Summary:

Assesses, plans and implements all aspects of medical and supporting services across the continuum of care for post-discharge members, promoting quality, cost effective care. Completes pre-admission and post-discharge medication reconciliation. Works with the care management and coordination teams to identify complex care transition support services.

Responsibilities:

• Assesses, plans and implements all aspects of medical and supporting services across the continuum of care for post-discharge members, promoting quality, cost effective care. Completes pre-admission and post-discharge medication reconciliation. Works with the care management and coordination teams to identify complex care transition support services.
• "Evaluates the needs of the member by completing clinical post-discharge assessments for members transitioning from healthcare facilities
• Evaluates medication and performs reconciliation between pre-admit and post-discharge medications
• Develops a care/service plan and collaborates with discharge planners, providers, specialists, and interdisciplinary teams to support member transition and discharge needs
• Assesses member current health status, resource needs, services, and treatment plans and provides appropriate interventions
• Facilitates transition into care management service for member based on acuity level
• Provides or facilitates education and resource materials to members, authorized caregivers, and providers to promote wellness activities to improve overall member quality of care
• Facilitates services between Primary Care Physician (PCP), specialists, medical providers, and non-medical resources as necessary to meet the medical and socio-economic needs of members
• May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources
• Serves as a subject matter expert to staff for clinical and non-clinical questions or issues related to post hospital outreach for members
• May precept new hires and support building core skills and providing guidance through the onboarding process
• Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators
• Provides feedback to leadership on opportunities to improve and enhance care and quality of delivery for members in a cost-effective manner
• Performs other duties as assigned
• Complies with all policies and standards"

Requirements:

• Required: Master's Degree in Behavioral Health Field or Clinical Social Work
• Required: LMHP, LCSW, LISW, LMSW, LMFT, LMHC
• MUST have NE licensure
• Years of experience required- 2 years
• Must haves: Empathy, strong communication skills, Critical thinking and ability to problem solve, ability to make decisions independently, self-starter & self-disciplined.
• Nice to haves: Substance use experience
• Disqualifiers: Don't have a NE License
• Performance indicators: We look at number of completed assessments to monitor performance

Skills

• Strong Communication Skills
• Knowledge of available behavioral health resources
• Ability to manage multiple technology systems