Care Manager, Rn

1 month ago

Ridgewood, United States CenterLight HealthCare, Inc Full time

PURPOSE:
Responsible for overall care management and quality of care for participants. Uses specialized knowledge of physical health, aging and loss, medication management and potential negative side effects, depression, challenging behaviors, Alzheimer’s Disease/Dementia, depression, behavioral health, and issues related to accessing and using durable medical equipment as appropriate. Appropriately documents any new findings in the member’s care management record.

Provides care coordination in a manner that is sensitive to age, gender, sexual orientation, cultural, linguistic, racial, ethnic, religious backgrounds, and congenital or acquired disabilities.

RESPONSIBILITIES:

- Participates and represents the Community Health Nurse (CHN) in all IDT meetings.
- The Care Manager will review all nursing documentation for quality and addresses any deficiencies.
- The Care Manager will review the UAS and the UAS analyzer system daily, run reports and follow up with the nurses on the accuracy of their assessments.
- Have regular meetings with their nurses to review caseload, participant status, and documentation.
- The Care Manager (CM) communicates with the CHN on a regular ongoing basis to coordinate a continuum of care consistent with the Member’s healthcare needs and goals. This care plan supports the Member in attaining and/or maintaining an optimal functional and health status.
- Coordinates the IDT meetings for the Members assigned to their case list.
- In coordination with the IDT, arranges, coordinates, and authorizes the provisions of appropriate services to meet identified member-specific needs (such as assistance with the Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), housing, home-delivered meals, and transportation) and when approved by the IDT, may authorize a range and amount of community-based services.
- Implements specific care management activities and/or interventions that lead to accomplishing the participants goals.
- Provides care management services across sites and collaborates with appropriate team members, facility, discharge planner and/or home care coordinator when members are transitioned between care settings.
- Documents services in accordance with CLHC standards and federal/state regulations
- Coordinates, facilitates, and arranges for long-term care services in nursing homes, rehab facilities, etc. as needed.
- Collaborates with PCP and other Specialty physicians and specialty-based services and members of IDT regarding any changes in participants condition to secure, arrange and coordinate all resources for implementing optimal care.
- Provides or arranges for ongoing Skilled nursing care and other skilled disciplines, service authorization and periodic assessment re assessment and evaluation of services
- Monitors care management activities, services, and member’ responses to interventions, to determine the effectiveness of the plan of care and the utilization of services and implements changes and adjustments to meet needs and resolve goals
- Evaluates the effectiveness of the plan of care in reaching desired goals and outcomes, make modifications or changes in the plan of care based on changes in the member’s health, as needed.
- Fiscally responsible in providing services based on member’s needs.
- Maintains up-to-date knowledge about current health-related issues, procedures, evidence-based clinical practices guidelines, medications and impacting health and practice standards.
- Serves as the Director of Patient Services (DPS) for the LHCSA.
- Serves as Manager on call during non-operational hours of the physical sites.
- Recommends and contributes to improvements in services, programs, policies, and procedures, to ensure optimum care and services to members.
- All other duties as assigned.

Performance Standards
- Performs consistent with organization’s mission and philosophy.
- Performs job responsibilities according to organization’s policies. Seeks clarification when needed.
- Assumes responsibility for assignments given, seeks supervision appropriately, and is accountable for work performance. Meets productivity guidelines.
- Maintains proper documentation (updated, timely, legible) related to patient care, whether paper or electronic.
- Maintains HIPAA standards and confidentiality of PHI.
- Supports staff, student, and volunteer orientation and ongoing in-service education as requested.
- Supports organizational activities by participating in quality improvement activities, special projects, internal and/or external committees, community activities, and other duties as assigned.
- Serves as a role model for peers and colleagues.
- Assumes responsibility for professional growth and development; maintains and upgrades professional knowledge and practice skills.
- Treats other CenterLight employees respectfully and facilitates an environment of teamwork.
- Initiates, if appropriate, incident reporting process and

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