RN Case Manager

3 days ago

Philadelphia, Pennsylvania, United States CAI Full time
Job Summary

We are seeking a highly motivated and experienced RN Case Manager to join our team in Delaware. As a RN Case Manager, you will be responsible for providing community-based care coordination and management for our clients' members in the state of Delaware.

Key Responsibilities
  • Travel to members' homes, nursing facilities, and other community-based settings to complete face-to-face needs assessments and 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 healthcare, social service, and custodial needs in a nursing facility or home and community-based care setting.
  • Coordinate care across the continuum of services and assist members with 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 healthcare 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 healthcare 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 make appropriate revisions as needed in accordance with policy and 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.
Requirements
  • Current Registered Nurse, licensed in the state of Delaware.
  • 5 years of Intensive Case Management and Discharge Planning experience, including experience discharging members from a facility setting.
  • Experience completing assessments, developing service plans, and care plans.
  • Experience collaborating with PCPs, Occupational Therapists, Behavioral Health, and Providers.
  • Experience with ordering DME equipment.
  • Experience educating and providing resources for the member's social determinants.
  • Working flexible hours to meet member 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 workspace 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.
Preferred Qualifications
  • 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.
Physical Demands

Ability to safely and successfully perform the essential job functions consistent with the ADA and other federal, state, and local standards. Ability to move about to accomplish tasks or move from one worksite to another. Regularly access low and high spaces that may be at irregular angles such as under a desk. Ability to conduct repetitive tasks on a computer, utilizing a mouse, keyboard, and monitor. Must be able to communicate with customers/team members over the phone and in person. Must be able to wear personal protective gear such as a helmet, goggles, mask, and protective footwear throughout the day.

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