RN Case Manager - Bilingual
5 days ago
Bronx
RN Case Manager – MLTC (Bilingual highly preferred) – Hybrid (4 days remote) Job Summary: The Nurse Care Manager is responsible for providing care coordination including in-home assessment, planning, facilitation, advocacy and authorization of covered plan services to meet the member's health needs while promoting quality cost effective outcomes. Essential Functions: • Ensures consistent care along the entire health care continuum by assessing and closely monitoring members’ needs and status., • Authorizes covered services and coordinates care regardless of payer., • Collaborates and communicates with member/family/caregivers, primary care practitioners, and the interdisciplinary team., • Works with member/family to maintain the most independent living situation possible, • Assesses, plans and provides continuous care management across all venues of care, including hospital, sub-acute, long-term and home settings., • Regularly assesses members for ongoing eligibility for services based on the specific plan’s eligibility criteria., • Performs home visits as required to assess members’ living situation, cultural influences, functional and cognitive needs., • Collaborates with the primary care physician and Inter-Disciplinary Team (IDT) to develop the Patient Centered Service Plan for the member., • Ensures appropriate, safe plan for members’ discharge from their plan., • Identifies same day grievances, investigates and documents accordingly. Documents any grievance according to plan policy., • Identifies and presents members with complex care management needs or in difficult to manage situations at Intensive Care management meetings (ICM)., • Responds to members’ requests in the designated timeframes and completes Initial Adverse Determinations (IAD) as indicated, • Identifies members requiring Care Management Review (CMR), evaluates documentation provided by the IDT including hospital or nursing home discharges planners, and formulates appropriate plan of care., • Documents care management/coordination according to company policy to the specific plan the member is enrolled in, which may include monthly telephonic and in person recertification notes., • Develops efficient plans of care, authorizing only needed services at the most appropriate levels, utilizing network providers and ensuring that services are based on members’ needs., • Associates degree in Nursing from an accredited nursing program required, • Bachelor's degree in Nursing preferred, • Three (3) years of experience as a registered nurse required, • Clinical experience in geriatrics and/or managed long-term care experience preferred, • Experience using multiple languages may be required based on operational needs Competencies, Knowledge and Skills:, • Intermediate proficiency level with Microsoft Office, including Outlook, Word and Excel, • Ability to communicate effectively with a diverse group of individuals, • Ability to multi-task and work independently within a team environment, • Knowledge of local, state & federal healthcare laws and regulations & all company policies regarding case management practices, • Adhere to code of ethics that aligns with professional practice, • Knowledge of and adherence to Case Management Society of America (CMSA) standards for case management practice, • Strong advocate for members at all levels of care, • Strong understanding and sensitivity of all cultures and demographic diversity, • Ability to interpret and implement current research findings, • Awareness of community & state support resources, • Critical listening and thinking skills, • Decision making and problem-solving skills, • Strong organizational and time management skills, • Bilingual speaking and writing skills are preferred Licensure and Certification:, • Current, unrestricted Registered Nurse licensure in the state of New York required, • Case Management Certification preferred Working Conditions:, • General office environment; may be required to sit or stand for extended periods of time #AC1 #ACP