The RN Care Manager improves clinical and cost-effective outcomes by reducing hospital admission and emergency department visits for members enrolled in VNSNY CHOICE Medicare and Medicaid, through on-going member education, care coordination and collaboration with providers of care. Provides telephonic case management to members, balancing clinical, social, and environmental concerns. Ensures services provided are in compliance with VNSNY CHOICE Medicare and Medicaid policies and procedures, as well as applicable state and federal regulations.
- Assesses, plans, facilitates and advocates for options and services to effectively manage an individual’s health needs. Leads the care coordination for complex clinical cases. Promotes quality and cost-effective outcomes at all times.
- Collaborates with physician and other healthcare professionals in managing coordination of care decisions related to case management and services provided to member enrolled in VNSNY CHOICE Medicare and Medicaid.
- Provides input and recommendations for design and development of, processes and procedures for effective member case management, efficient department operations, and excellent customer service.
- Provides analysis of initial health evaluation and comprehensive assessment of the member/family psychosocial status and case management needs.Participates in the development, coordination and implementation of the care plan to address specific needs of the member/family including thorough transitions between settings of care.
- Reviews covered and coordinated services in accordance with established plan benefits, application of evidenced based medical criteria, and regulatory requirements to ensure appropriate authorization of services and execution of the plan’s fiduciary responsibilities.
- License and current registration to practice as a registered professional nurse in New York State required. Certified Case Manager Certification preferred.
- Associate Degree in Nursing required. Bachelor’s or Master’s Degree in Nursing preferred.
- Minimum of two years of case management experience assessing needs, coordinating/collaborating services and referrals required.
- Case management experience in a managed care organization or health plan preferred. Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills required.
- Working knowledge of Microsoft Excel, Power-Point, and Word required.
- Knowledge of Medicare/Medicaid and/or commercial regulations preferred..
- Knowledge of Milliman criteria (MCG) preferred