Provides care management through a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet member’s health needs through communication and available resources, while promoting quality cost-effective outcomes. Maintains members in the most independent living situation possible; ensures consistent care along entire health care continuum by assessing and closely monitoring members’ needs and status. Provides care management services and authorizes/ coordinates services within a capitated managed care system. Closely communicates and collaborates with primary care practitioners, interdisciplinary team and family members. Works under general supervision.
- Assesses, plans and provides intensive and continuous care management across acute, home, and long-term care settings. Develops and negotiates care plans with members, families and physicians.
- Assesses a person’s living condition/situation, cultural influences, and functioning to identify the individual’s needs; develops a comprehensive care plan that addresses those needs.
- Assesses an enrollee’s eligibility for Program services based on his or her health, medical, financial, legal and psychosocial status, initially and on an ongoing basis.
- Plans specific objectives, goals and actions designed to meet the member’s needs as identified in the assessment process that are action-oriented, time-specific and cost effective.
- Implements specific care management activities and or interventions that lead to accomplishing the goals set forth in the plan of care.
- Coordinates, facilitates and arranges for long term care services in the home and community-based sites, such as adult day care, nursing homes, rehab facilities, etc. Arranges for on-going nursing care, service authorization and periodic assessment.
- Collaborates and negotiates with interdisciplinary teams, health care providers, family members, and third party payors, as applicable, across all health settings to ensure optimum delivery and coordination of services to members.
- Monitors care management activities, services, and members’ responses to interventions, to determine the effectiveness of the plan of care and the utilization of services.
- Evaluates the effectiveness of the plan of care in reaching desired outcomes and goals; makes modifications or changes in the plan of care as needed.
- Identifies trends and needs of groups in the community and plans interventions based on these identified needs.
- Provides care management services across sites and collaborates with appropriate facility discharge planner and/or HCC when members are transitioned between settings.
- Manages expenditures to ensure effective use of covered services within a capitated rate. Fiscally responsible in providing services based on members’ needs.
- Visits members in their homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options to deliver direct care to the patient.
- Provides social work services in accordance with NASW code of ethics, Agency policies, practices, and procedures.
- Participates in outreach activities to promote knowledge of the Program and its services and to coordinate Program activities with outside community agencies and health care providers (e.g., community health screening, In Services).
- Participates in the development of programs to meet the specialized needs of this selected patient population.
- Documents services in accordance with VNSNY CHOICE Community Care standards and Managed Long Term Care (MLTC) and Licensed Home Care Services Agency (LHCSA) regulations.
- Participates in special projects and performs other duties as requested.
For Palliative Care Only:
- Understands and supports ability to cope with patients’ illness. Provides emotional, spiritual, and practical support for patient and family
- Reviews tools, programs and other resources for potential serious illness program appropriate patients and make referral as necessary.
- Provides education to patients and their families to better understand patients’ disease and diagnosis.
- Facilitates open discussion about treatment choices for patient’s illness (including difficult and complex choices) and management of symptoms
- Provides expertise in treatment of pain and other symptoms
Licensure:License and current registration to practice as a Licensed Social Worker in New York State preferred.
Education: Master’s degree in Social Work after successfully completing a prescribed course of study at a graduate school of Social Work accredited by the Council on Social Work Education and the Education Dept. and who is certified or licensed by the Education Dept to practice Social Work Education in New York State, required. Case Management Certification preferred.
Experience:Minimum of three years MSW experience required. Minimum of two years in a case management and/or community based environment preferred. Bilingual skills may be required, as determined by operational needs. Clinical expertise in geriatrics, Long Term care and Managed care experience preferred.
The Visiting Nurse Service of New York (VNSNY) is one of the nation's largest not-for-profit home- and community-based health care organizations, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Counties. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost-effective health care in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, health plan members, and clients from before birth to the end of life. On any given day, VNSNY employees - including nurses, rehabilitation therapists, social workers, home health aides and other professionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to approximately 40,000 individuals in our care helping them to live the best lives possible in their homes and communities.