Claims-CW - Care Manager, RN - CW

Job Responsibilities:

• Travel to members’ homes (occasionally a hospital or motel and very rarely a long-term care facility or nursing home) and other community based settings in order to complete face to face needs assessments with subsequent telephonic contact with the member in accordance with state and national guidelines, policies, procedures, and protocols.
• Assess, plan, coordinate, implement and evaluate care for eligible members with chronic and complex health care, social service and custodial needs in a nursing facility or home and community-based care setting.
• Coordinate care across the continuum of services and assisting members physical, behavioral, long term services and supports (LTSS), social, and psychosocial needs in the safest, least restrictive way possible while considering the most cost-effective way to address those needs.
• Facilitate authorization, coordination, continuity and appropriateness of care and services in community or HCBS.
• Facilitate transitions to alternate care settings such as hospital to home, nursing facility to community setting using an integrated care team to address the member’s specific needs.
• Educate members or caregivers regarding health care needs, available benefits, resources and services including available options for long term care community or facility-based service delivery.
• Provide education, resources, and assistance to help members achieve goals as outlined in their plan of care and to overcome obstacles to achieving optimal care in the least restrictive environment.
• Develop a plan of care in conjunction with members or caregivers to identify services to meet the member’s specific needs, and goals.
• Identify resources needed for a fully integrated care coordination approach including facilitating referrals to special programs such as Disease/Chronic Condition Management, Behavioral Health, and Complex Case Management.
• Collaborate with the member's health care and service delivery team including the DSHP Plus LTSS Member Advocate, ICT, and discharge planners, to coordinate the care needs and community resources for the member in order to maintain the member in the least restrictive safe environment possible. Assist members in developing, implementing and amending a back-up plan for gaps in provider coverage.
• Ensure approved support services are being provided as outlined in the plan of care. Evaluate the effectiveness of the service plan and making appropriate revisions as needed in accordance with per policy & procedures and state contractual requirements.
• Assist members in overcoming obstacles to optimal care through connection with community resources, including communicating with providers and formulating an appropriate action plan.
• Document all case management services and intervention in the electronic health record. Adhere to all company, State and Federal requirements related to privacy practices, HIPAA, and quality performance standards.
• Perform other duties as assigned/requested.

Skills:

• Registered Nurse in the state of DE, with case management experience
• Experience completing Assessments, developing Service Plans and Care Plans
• Experience collaborating with PCP’s, Occupational Therapists, Behavioral Health, and Providers
• Experience with ordering DME Equipment
• Experience educating and providing resources for the member’s Social Determinants. They must have experience with discharging members from a Facility setting.
• Working flexible hours to meet member’s needs
• Proficiency in PC-based word processing and database documentation (Word, Excel, Internet, Outlook)
• Reliable transportation daily to be able to travel within assigned territory
• Ability to meet regulatory deadlines.
• Has a dedicated home work space used only for business purposes and is able to comply with all telecommuter policies.
• Experience in geriatric special needs, behavioral health, home health
• Understanding of the importance of cultural competency in addressing targeted populations.
• Experience with electronic documentation systems
• Experience with cost neutrality and budgeting
• Must be willing to travel throughout the state (may only need to travel 2-3 times a week depending on schedule)
• Must be able to communicate clearly to members - will be tasked with conducting assessments with members over the phone
• Must be very organized

Education/Experience:

• Certified Case Manager (CCM)
• Licensed Bachelor’s Social Worker (LBSW)
• Licensed Master’s Social Worker (LMSW)
• Licensed Clinical Social Worker (LCSW)
• Experience working with HIV/AIDS population
• Experience working with behavioral health population
• Experience working with developmental disabilities population
• Medicare and Medicaid experience