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Job DescriptionPrime Care Coordination is a human services agency that partners with people with intellectual and/or developmental disabilities to help them receive services and supports they need to live their lives in the most meaningful way. We are seeking a dedicated Care Manager to join our team! The schedule is Monday-Friday (8 hour shift with no On-Call!) This position is a hybrid/remote position. PCC Values Its Employees by offering: • Paid time off (25 days per year), • 10 Paid Holidays, • Affordable health care coverage including health, dental, vision, starting as low as $10.00/month, • 401(K) Retirement plan, • Tuition Reimbursement, • Generous Employee referral program, • Employee Wellness Program (earn up to $250 per year!), • Numerous other benefits, please apply to find out more! Summary: The Care Manager’s primary function is to work in partnership with individuals with I/DD to coordinate care and services needed to assist individuals achieve optimal health, wellness, and life goals. The Care Manager is responsible to provide Health Home core services including comprehensive care management, care coordination and health promotion, comprehensive transitional care, individual and family support, referral to community and social support services, and use of Health Information Technology to link services. Care Managers will provide all services with a person-centered approach and that aligns with NYS OPWDD Valued Outcomes. Essential Job Functions: • Conduct comprehensive assessments to identify an individual’s clinical and psychosocial needs, choices, and preferences for services, • Assess and address health and safety issues as well as barriers to care and treatment including social determinants of health, • Collaborate with interdisciplinary team and incorporate input into comprehensive assessment and Life Plan, • Develop and maintain a person-centered Life Plan that coordinates and integrates an individual’s clinical and non-clinical healthcare related needs and services, • Monitor and facilitate implementation of and provide updates as needed to the Life Plan, • Incorporate health promotion and support opportunities for individuals to achieve and maintain optimal health and wellbeing, • Coordinate and ensure access to chronic disease management, • Facilitate referrals to clinical and community resources, including planning, referrals, and follow-up for transitional care, • Coordinate and provide access to long-term care supports and services, • Engage families and natural supports into the care coordination process, • Ensure all individuals and families receive services that are culturally and linguistically appropriate, • Advocate on behalf of the individual, • Promote self-advocacy and the ability to self-direct, • Use Health Information Technology for documentation, to link services, and facilitate communication among care coordination team, • Secure all health records and other protected information with the highest regard to confidentiality and HIPAA laws and regulations, • Maintain compliance with all state and federal laws and regulations, Medicaid compliance, and PCC policies and procedures, • Document all services and maintain appropriate records following all established documentation procedures, • Represent PCC on workgroups, committees, advisory groups or networks as assigned, • Participate in opportunities for continued training and education, • Ability to act quickly, assess and act accordingly in crisis situations, • Basic technology skills and understanding of health records, • Knowledge of ethical and professional responsibilities and boundaries, • Demonstrate professional work habits including dependability, time management, independence and responsibility, • Bachelor’s degree with two years of relevant experience OR, • A license as a Registered Nurse with two years of relevant experience, which can include any employment experience and is not limited to case management/service coordination duties OR, • Ability to sit/stand throughout day to accomplish job, • Ability to enter data, notes, and other documentation into a computer., • Must be able to travel throughout covered territories in Upstate NY as needed. The listed salary range represents the organization's good faith and reasonable estimate of the range of possible compensation at the time of posting. The offered salary will be determined by: Applicant qualifications and experience, education, position specific licensing/training and departmental budgets. Prime Care Coordination is committed to equal employment opportunity. We recruit, employ, train, compensate, and promote without regard to race, religion, color, national origin, age, sex, disability, protected veteran status, or any other basis protected by applicable federal, state, or local law. Prime Care Coordination will make reasonable accommodations for known physical or mental limitations of otherwise qualified employees and applicants with disabilities unless the accommodation would impose an undue hardship on the operation of our business. If you are interested in applying for an employment opportunity and feel you need a reasonable accommodation pursuant to the ADA, please contact us at 585-347-1037.

Job Description Role and Responsibilities The Afterhours/Weekend Clinical Field Staff Supervisor (CFSS) is an integral part of the patient care team and continually monitors the services provided. This role has shared responsibility for the overall provision and coordination of home health services provided to the HCR patients according to acceptable standards of practice. The Afterhours/Weekend CFSS is a resource person with extensive knowledge of the regulatory guidelines governing home health agencies and provides daily support to field clinicians enabling them to provide quality care in the home to HCR patients. This position may be remote, with appropriate approvals, and provides service, coordination, management during afterhours and on the weekends, and is a liaison between referral resources, patients, caregivers, and employees. Essential Functions • Act as liaison, to assist in appropriate ongoing management of care; ensure appropriate plans and interventions are identified, act as resource for problem-solving or advising on patient care questions or concerns., • Review and approve all new interim orders before they are sent to physician. Notify Clinical Manager/Regional Director if unable to approve the order., • Assure orders are written according to HCR protocol/regulatory requirements., • Update pathways, as needed, in Point Care to provide intervention and goals for documentation to include vital sign alert., • Review missed visit reports, ensure MD notification has occurred and, if not, notify MD., • Ensure clinical documentation is present to support the patient’s need for ongoing services., • Review and process all wound score deviations, documenting any action and/or follow-up., • Review and process vital sign alert reports including documenting any action, follow-up and physician notification., • Perform end-of-episode reviews, ensuring regulatory requirements are met., • Review and process discharges (discipline and agency)., • Review and process discipline-only discharges., • Review evaluation documentation task (push SOC to coding and Recert to held stage)., • Receive and review lab reports and assess for normality. Review new lab order via fax and email clinician to review and notify case manager and physician, as appropriate., • Entry of Hospital Hold Order/Note, if needed, including follow-up on patient status at hospital., • Follow-up with staff to correct or refine documentation that is not accurate or complete, to ensure standards of documentation are met., • Support staff by assisting with administrative clinical functions (i.e., TIFs, phone calls, etc.)., • Alert Clinical Manager/Regional Director of changes in patient status or orders that do not seem appropriate., • Enter information regarding all telephone calls into the coordination notes section of HCHB., • Notify staff, as appropriate, to ensure proper coordination of care., • Adhere to, and participate in, the Agency’s mandatory HIPAA/Privacy Program and Employee Compliance Program., • Read and adhere to all Agency policies and procedures and follow the Employee Handbook Guidelines., • Quality:, • Audit clinical records to identify trends/areas of improvement in processes and documentation., • Collaborate with Clinical management and Staff Development departments, to inform of findings of audits, outcome measurements, notify of trends and potential educational needs., • Clinical assistance:, • Triage incoming calls., • Audit/Review DRRs., • Other duties as assigned. This job description reflects management’s assignment of essential functions; and nothing in this herein restricts management’s right to assign or reassign duties and responsibilities to this job at any time. Education Requirements • Bachelor of Science Degree in Nursing preferred. Qualifications and Requirements • Current, valid licensure as Registered Professional Nurse issued by NYS Department of Education., • Two (2) years’ experience in the health care industry with a minimum of 1 year experience in home health care., • Supervisory experience is preferred., • Understand issues related to the delivery of home health services and be able to problem-solve effectively., • Possesses knowledge of the Medicare/Medicaid guidelines governing home health agencies., • Organized, detail-oriented, and possesses effective oral and written communication skills., • Able to work independently, with minimal direction or management oversight., • Excellent customer service skills. Work Environment The Afterhours/Weekend CFSS is primarily in an office setting and may be exposed to outdoor conditions. The working conditions are classified as sedentary work: • Sedentary work - Exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Physical Requirements The following is a description of the physical requirements on a daily basis for the Afterhours/Weekend CFSS. While performing the duties of the job the employee is regularly expected to: • Stand, • Sit, • Hear, • Walk, • Talk, • Stoop or kneel, • Repetitive motion This is not necessarily an exhaustive list of all responsibilities, duties, skills, efforts, requirements or working conditions associated with the job. While this is intended to be an accurate reflection of the current job, management reserves the right to revise the job or to require that other or different tasks be performed as assigned. EOE/AA Minority / Female / Disability / Veteran #ZR