Provides care coordination interventions including planning, facilitation, and advocacy of covered plan services to meet a patient’s health needs, while promoting quality cost-effective outcomes. Provides effective and comprehensive nursing care coordination in accordance with the American Nurses Association (ANA) Scope and Standards of Practice, the New York State Article 139, Nurse Practice Act. Partners with patients to maintain the most independent living situation possible and facilitates consistent care along a patient’s entire health care continuum and available community resources. Reassesses and closely monitors patients’ needs and status to facilitate the appropriate delivery of healthcare services. Communicates and collaborates with primary care practitioners, family members, informal care givers, and the interdisciplinary team (IDT). Works under general supervision.
- Provides care coordination through a collaborative process of planning, facilitation and advocacy for options and services to meet patients health needs. Communicates resources and services available to patients through the continuum of care.
- Reviews clinical reports of providers for relevant patient data, communicates patient condition to payor case manager in a manner that is focused and reflects knowledge/understanding of patient condition/progress, and negotiates authorizations consistent with clinical data.
- Ensures interventions are aligned with CMS Triple Aim framework: improving the patient’s experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare.
- Identifies patient specific problems, goals and interventions designed to meet the patient’s needs as identified in the assessment/reassessment process that are action-oriented, time-specific and cost effective. Addresses any patient concerns to ensure satisfaction with overall services provided and uses motivational interviewing techniques to foster behavioral changes.
- Ensures appropriate utilization of home health aides and other resources for optimal, cost effective care and services by reviewing clinical reports. Establishes on-going dialogue with payor case managers and Partners field staff.
- Directs field staff to take actions that address issues and improve performance, including changing plans of care and notifies payor case manager of significant changes in patient condition. Evaluates performance and reports assessments to clinical management and works with them to set accountability mechanisms and long-term correction standards.
- Demonstrates awareness of circumstances necessitating revisions to the plan of care, such as changes in the client’s condition, lack of response to the care plan, preference changes, transitions across settings, and barriers to care and services.
- Coordinates the implementation of specific aspects of the plan of care activities and/or interventions that lead to accomplishing the goals set forth in the plan of care.
- Facilitates communication and coordination among patients’ health care team, involving the patient in the decision-making process in order to minimize fragmentation of services.
- Monitors care management activities, services, and patients’ responses to interventions. Evaluates the effectiveness and utilization of care plan services in reaching desired outcomes and goals; makes recommendations for modifications or changes to the plan of care as needed.
- Identifies trends and needs based on the cultural and demographic diversity of the population; plans interventions based on these population health needs.
- Documents relevant, comprehensive information and data using standard assessment and tools supporting the plan of care and organized care coordination systems aimed at improving the outcomes of patients served both individually and collectively.
- Ensures compliance with all federal, state, and local managed care and licensed agency regulations.
- Educates the patients, family or care-giver, and members of the health care delivery team about treatment options, and explores where possible, alternative plans to achieve desired outcomes.
- Strives to continuously improve patient outcomes to achieve optimal levels of health, adherence to the plan of care including patient safety and satisfaction, medication adherence, and assisting the patient to navigate the health care system and transitions to attain optimal outcomes.
- Performs all duties inherent in a managerial role. Ensures effective staff training, evaluates staff performance, provides input for the development of the department budget, and hires, promotes and terminates staff and recommends salary actions, as appropriate.
- Participates in special projects and performs other duties as requested.
Licensure: License and current registration to practice as a registered professional nurse in New York State required.
Education: Bachelor’s Degree in Nursing (BSN) from an approved program preferred.
Experience: Minimum of three years of experience as a registered nurse required. Minimum of two years of care management experience required. Clinical expertise in geriatric care preferred. Bilingual skills may be required, as determined by operational need.
The Visiting Nurse Service of New York (VNSNY) is the nation's largest not-for-profit home- and community-based health care organization, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Countries. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost effective healthcare in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, members, and clients from before birth to the end of life. Each day, more than 13,000 VNSNY employees - including nurses, rehabilitation therapists, social workers, other allied professionals, and paraprofessionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to more than 44,000 patients and members, helping them to live the best lives possible in their homes and communities.