HIGH RISK NURSE CASE MANAGER
Active in the NY Metro Area since 1996 and now the largest physician-owned independent physician association in the Northeast, HealthCare Partners Management Service Organization (HCP) offers a new full-time opportunity based in Garden City!
HIGH RISK NURSE CASE MANAGER
To Provide Intensive Care Management Services to High Risk Members
- Receive referrals from HCP’s software system based on knowledge of third party nationally approved criteria, claims, Inpatient. Team Risk Stratification, and Network Provider Referrals.
- Review census daily and coordinate with Care Team Members.
- Review member’s record in the HCP system.
- Review GHMO tiers for additional members to be enrolled.
- Coordinate with the HCP team for discharge planning and authorization needs.
- Engage with member and family/caregivers telephonically to introduce CM’s role and provide contact information. Foster a member/team engagement throughout enrollment and transition the appropriate state and federal program, as needed.
- Responsible for all pre-service reviews for members.
- Arrange/Perform home assessment prior to discharge to assess for member’s home care environment and equipment needs with assist of Inpatient Team and or NP home visit.
- Review home risk factors, transitional barriers with member and family.
- Review for additional insurance: Long Term Care policy, Veteran benefits, etc. if additional support services are needed.
- Review support system: family, private care, Faith Community Nurse, etc.
- Make recommendations for additional services, as indicated, (Home Health, Companion, Medical equipment, Assisted Living, MLTC Plus, etc.).Makes introduction to the selected Network providers and educate member specific needs. Develop relationships to assure open communication to provide seamless transition of care between health care settings. Coordinate with NP Transition.
- Make second contact within two (2) business day with the member post discharge from acute care facility.
- Facilitate Home Health referral post SNF, IRF or LTAC discharge, as indicated.
- Facilitate NP home visits ad hoc, weekly with NP, home health or SNF staff to review plan of care and plan for transitional barriers. Make telephonic contact as indicated.
- Assure there are follow up visits scheduled with all outpatient providers including primary physician, specialty care physician(s), outpatient physical therapy, as indicated, etc., Assure that member has transportation.
- Medication management is secured within 48-72 hours of the discharge to home care. Medication Reconciliation is completed weekly, as indicated.
- Review additional medical records from health care providers to assure care plan is followed and member’s response to treatment and care.
- Assist in the development of a comprehensive member centric care plan that includes clinical, psycho-social, financial and environmental needs. Make recommendations for changes in care plan that incorporate transitional barriers, as indicated.
- Attend rounds, if needed.
- Advise on transition to least restrictive, medically appropriate level of care. Assure there is a seamless transition of care between health care settings.
- Make recommendations for additional services, as indicated:
- Outpatient wound care clinic
- Hospice/palliative care, as indicated
- Other disciplines within the home health team (MSW, OT, ST, PT, SN and HHA)
- Outpatient rehabilitation clinic
- Behavioral Health services
- Personal Care support services
- Community based services: Meals on Wheels, adult day care
- Immunization updates
- Assisted Living
Skills, Knowledge, Abilities Required:
- Excellent written and oral communication.
- Experience working with high risk/geriatric population preferred.
- Independent problem identification/resolution and critical decision making.
- Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
- Interdisciplinary team player, detail oriented and flexible.
- Knowledge of Managed Medicare/Medicaid reimbursement guidelines for home health
- Proficient with Microsoft Office applications.
- Knowledge of InterQual and Milliman.
- Knowledge of NCQA and URAC standards a plus.
- NYS Licensed RN, BSN preferred.
- Case Management Certification preferred.
- 2+ yrs. Insurance/MSO Care/Case Management /High Intensity preferred.
- 4+ yrs. Home Health Case Management experience a plus.