The Hospital to Home Care Manager will navigate a variety of applications and platforms in the daily administration of work. They must combine strong clinical knowledge and critical thinking to coordinate and support a care plan that will monitor quality medical care for the member population serviced by CDPHP. This position may be in a hospital facility or at CDPHP and/or telephonically depending on the needs of the business unit. Since the position can be based in one or more Hospital to Home facilities it requires hospital clearance and compliance with any hospital standards (ie. physical exam, PPD, up to date with vaccinations).

• Registered Nurse with a current New York State license is required.
• Associates degree required. Bachelor's degree Preferred.
• Certified Case Manager (CCM) certification preferred.
• PRI (Patient Review Instrument) certification preferred.
• Minimum three (3) years clinical experience is required.
• Experience with chronic condition management required, experience with diabetes and heart disease is preferred.
• Case management experience preferred.
• Experience working with health, social service and funding resources, including community agencies and alternate care delivery systems is preferred.
• Experience in home care, medical office setting or managed health plan preferred.
• Experience with Microsoft Office, including Word, Excel, Outlook and PowerPoint is required
• Demonstrated ability to provide case management for complicated members with multiple comorbidities and chronic diseases.
• Demonstrated ability to develop rapport and anticipate a member needs through ongoing communication and coordination with families, hospitals, providers etc.
• Demonstrated ability to work collaboratively with multiple partners to positively affect outcomes at the team, organization, and member level.
• Demonstrated ability to communicate effectively with members with varying levels of education, health literacy and understanding.
• Demonstrated ability to work with diverse population.
• Ability to navigate system applications with accuracy.
• Demonstrated ability to pro-actively identify problems, as well as recommend and/or implement effective solutions.
• Demonstrated ability to interact with providers, members to positively impact the quality of patient care.
• Demonstrated ability to review health care delivery against established criteria.
• Demonstrated ability to manage multiple projects in conjunction with a frequently changing patient caseload.
• Demonstrated ability to work with and maintain confidential information.
• Demonstrated ability to provide excellent customer service and develop relationships both internally and externally.
• Excellent verbal and written communication skills.
• Flexibility to adapt to a changing and fast-paced environment.
• Ability to travel to a variety of sites across CDPHP service area, during regular business hours, evenings and possibly weekends may be required. Position requires someone who is flexible on a day-to-day basis to travel to facilities in the Capital District.
• Valid driver's license and driving record showing no restrictions that would impede ability to travel by automobile required.
• Annual physical assessment will be required, as well as any other clinical requirements requested by the designated facility.
• Multilingual is preferred.