Care Manager - Cluster Care

Brooklyn, NY

Post Date: 08/08/2017 Job ID: 23035 Category: Registered Nurse

  • The manager is flexible with the start time.
  • Care Manager usually get started between 9am and 10am.

Job Description:
  • This business unit is experiencing growth and is in need of a Care Manager RN.
  • The selected candidate will oversee the care of member who will be transitioning to the community.
  • He/She will be assigned to 1-2 transitional homes.
  • The member caseload of about 125.
  • Responsible for the assessment, reassessment, care planning and coordination of care and services.
  • Includes ongoing monitoring of an appropriate and effective person centered care plan, member education and care management.
  • Regularly communicates with the members PCP and other providers, and integrates the member, caregiver and other provider feedback into the assessment and planning.

Essential Functions:
  • Completes UAS and other relevant screening and assessment tools in the member home.
  • Ensures continuity of care for newly enrolled members.
  • Identifies and prioritizes the member s needs and preferences.
  • Develops quantifiable goals and desired outcomes, and promotes the members ability to self-manage to the greatest extent possible.
  • Develops, implements and monitors the Person Centered Service Plan, assisting members in obtaining reasonable accommodations when appropriate.
  • Manages case load, including risk stratification of members, monitoring reassessment needs and facilitating transitions of care settings.
  • Serves as the primary point of member contact.
  • Assesses member needs, manages care and services, and ensures effective communication among members, caregivers, providers and community supports.
  • As the lead of the interdisciplinary team, facilitates the activities and communication within an interdisciplinary team of providers, vendors, facilities, discharge planners, field nurses, social workers, care coordinators, and member/caregivers to effectively manage care plans and transitions of care settings.
  • Maintains timely, complete and accurate documentation using both hard copy and technology based solutions in compliance with regulatory policies and procedures.
  • Gathers and summarizes data for reports.
  • Supports initiatives of the Quality Assessment and Performance Improvement Committee.
  • All other duties as assigned.

  • Valid RN License.
  • Bachelor s Degree.
  • 2+ years experience in Behavioral Health.
  • Clinical experience with a focus in managed care, including disease or case management.
  • Home Care, Long-Term Care, MLTC experience preferred, including appropriate support services in the community and accessing and using durable medical equipment (DME).
  • Experience in utilization review, concurrent review and/or risk management a plus.

  • Understands and is able to apply principals of Care Management and Person Centered Service Planning.
  • Ability to apply Care Guidelines and other applicable, evidenced-based clinical guidelines.
  • Ability to understand and apply coverage guidelines and benefit limitations.
  • Familiar with clinical needs and disease processes for chronic physical and behavioral illnesses (depression, challenging behaviors, Alzheimer s disease and other disease-related dementias).
  • Understands and adapts appropriately to issues related to communication, cognitive or other barriers.
  • Ability to lead an interdisciplinary care team.
  • Strong organizational skills and the ability to prioritize and follow through on multiple projects in a timely manner.
  • Comfortable with conducting home visits and commuting within the service area.

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