OverviewProvides telephonic clinical care management services using evidence-based practices to ensure effective utilization of benefits, services, and care is provided to the patients allowing them to remain safely in their home/community.
Compensation:$49.55 - $61.96 Hourly
What You Will Do
- Coordinates and/or oversees the coordination of benefits and services for all members on his/her caseload.
- Completes care management and disease specific assessments.
- Makes timely telephonic care management calls based on risk level.
- Resolves and coordinates complex issues and member complaints impacting the delivery of services.
- Provides health education to member/caregiver.
- Assesses SDoH and provides care coordination to reduce/remove barriers of care to include ability to allow for changing levels of care based on assessments, trigger events and program data/reports.
- Identifies member safety issues and intervenes as necessary or refers to appropriate resources, such as community linkages, dietary, therapy (PT/OT/ST), HHA services, behavioral health, and DME.
- Coordinates the delivery of high quality, cost-effective care based on a customized population model of care supported by evidence based clinical practice guidelines.
- Advocates for the member/caregiver to obtain the health care and other services needed to optimize their quality of life.
- Utilizes the Care Management process to set priorities, plan, organize and implement interventions that are goal directed towards self-care outcomes and the transition to independent status.
- Promotes adherence to the physician treatment plan by providing education, coaching and support.
- Educates, coordinates, and provides resources to reduce inappropriate utilization of emergency room (ER) and hospital service.
- Increases utilization of primary care, specialty care, preventive health and guideline-based treatments including proper pharmacotherapy within network, as appropriate.
- Participates in interdisciplinary team (IDT) meetings and provides input on customer service-related activities.
- Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
- Ensures compliance with payors' policies and procedures as well as all Federal and State regulations.
- Interprets and implements VNS Health policies, state and federal regulations.
- Participates in special projects and performs other duties as assigned.
QualificationsLicenses and Certifications:
- License and current registration to practice as a Registered Professional Nurse in NYS required or
- New York State License and current registration in Physical Therapy required or
- New York State License and current registration in Occupational Therapy required
- Certified Case Manager - Commission for Case Manager Certification within 1 year of employment required
Education:
- Associate's Degree in nursing required or
- Bachelor's Degree in Physical Therapy from a program approved by the New York State Department of Education required
- Bachelor's Degree in nursing preferred
Work Experience:
- Minimum two years of experience in health related field required
- Care management and/or managed care experience preferred
- Proficiency in Microsoft Office applications required
- Demonstrated analytical skills required
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