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Description/Comment:NResponsible for long-term care management of eligible Healthcare members with complex care needs; partners with an interdisciplinary team to deliver comprehensive, community-based care management services focused on helping the member maximize best health outcomes. Interacts with members in-person, in their home on a regular basis; also meets members at work-sites, a physician’s office, or at an agreed upon community location such as a library. Interacts with members telephonically following at least the minimum standard of contact required per member based on their level of intervention. Completes in-person assessments while maintaining a larger caseload telephonically. Conducts individualized assessments to identify problems, goals, & interventions with corresponding measurable outcomes that drive the content of the holistic, member centered care plan. Develops a healthy action plan in partnership with the member, defining problems, goals, and objectives to improve the member’s overall wellbeing/quality of life, continuously partners with the member to evaluate the member’s progress in setting/meeting the established goals, revising/updating the health action plan accordingly. Utilizes influencing and motivational interviewing skills to ensure maximum member engagement; promotes lifestyle and behavior changes to achieve optimum level of health. Helps members actively and knowledgeably participate with providers in healthcare decision-making; helps members actively and knowledgeably participate with community based organizations able to support in meeting health goals. Conducts assessments for members discharged from an in-patient hospital or skilled nursing facility, supports post discharge plan of care for both members assigned within their case load and members outside of the case load but residing within their local community. Demonstrates proficiency with operating in a remote environment, connecting hardware/software, managing email in an Outlook account, and using remote communication software such as Skype & WebEx; able to demonstrate proficiency with Word, Excel, and experience documenting within an electronic health record. Other requirements include: ability to travel within a designated geographic area for in-person care management activities – distance is reasonable but not fully defined by one-way mileage limits.
Additional Job Details:This employee will work in the field visiting members. Would like them to work from home if possible. • Active Registered Nurse License (RN), active and in good standing required • Certified Managed Care Nurse (CMCN) or CCM preferred. Minimum of 3 years’ care/case management experience required Minimum of 3 years clinical experience required; Registered Nurse with active state license in good standing CCM Certification desired 1+ years of community based experience preferred, particularly within an interdisciplinary care team Health Plan experience preferred - Managed Care, Medicare/Medicaid, or Commercial Professional certifications preferred (CMCN, GCM, CRC, CDMS, CRRN, COHN, or CCM) The ability to express oneself clearly both in writing and verbally Bilingual (Spanish) preferred.
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