What are the responsibilities and job description for the Registered Nurse, Care Management position at Family Choice of New York?
Job Description
Due to rapid growth, Family Choice is seeking to fill multiple positions. The Care Management RN has a key role in ensuring that the member is receiving the most efficient care possible in the most appropriate setting, including the safe and effective transition of members across the care continuum and ensuring the member’s needs are met.
Tasks
Due to rapid growth, Family Choice is seeking to fill multiple positions. The Care Management RN has a key role in ensuring that the member is receiving the most efficient care possible in the most appropriate setting, including the safe and effective transition of members across the care continuum and ensuring the member’s needs are met.
Tasks
- Complete in-home visits and maintain regular communication with assigned members as per Risk Stratification or more frequently based on member needs.
- Within the scope of licensure, continually assess member care needs to assure they are receiving the care ordered in the most effective setting and that the care provided is appropriate.
- Ensure timely completion of HRA per regulations and FC policies.
- Develop individualized care plans for members and ensure all care plans of assigned members within the team are thoroughly reviewed and signed.
- Utilize guidelines provided by IH and FCNY in assessing member needs.
- Complete visits and documentation per company guidelines in a timely manner.
- Each member visit note must include subjective data gathered from member, caregiver or other members of the interdisciplinary team as well as an appropriate physical assessment of the member. Assess and document findings in the appropriate care management system per FC policy.
- Following a transition of care, ensure that the receiving health care facility/setting understands the member’s needs and have the information they need to provide effective care following the transition.
- Review and discuss the Transition Plan with the patient, his/her family, friends (if appropriate) and professional staff to ensure understanding and agreement.
- Following a transition, collaborate with member, family, and providers to ensure that the discharge plan reflects the right care, at the right time, and in the right setting.
- Provide information and guidance to the patient and/or family for an effective care transition, improved self-management skills, and enhanced patient-healthcare provider communication.
- Identify the need for social work intervention and/or assist member or families/caregivers with linkage/access to community resources, financial assistance, and/or advanced care planning.
- Coordinate and facilitate the member’s access to services with other health care providers including mental health providers as needed.
- Identify the potential need for additional medical services such as homecare or medical office visits. If appropriate collaborate with the primary care provider and/or specialists to facilitate appropriate referrals.
- Ensure or arrange that proper HIPAA documentation has been completed when speaking with anyone on behalf of the member.
- May be required to answer member’s calls after hours to provide clinical guidance for urgent issues.
- Attend meetings as requested.
- Complete all Care Management forms and documentation as directed.
- Assist with training and oversight of new team members per management’s request.
- Build rapport with hospitalists, physician consultants, nurses and discharge planners to facilitate identification of high-risk patients, estimate dates of discharge, probable discharge dispositions, etc.
- Facilitate member physician post-hospital visits by providing a list of questions for the physician as needed and following up on diagnostic testing ordered for the member.
- Other duties as assigned.
- RN licensed in New York State
- Bachelor’s degree preferred
- Certified Case Management (CCM) preferred
- Minimum of 3 years’ experience, preferably in or related to Care Management/Case Management/Discharge Planning.
- Excellent written, verbal, and listening communication abilities.
- Experience in Managed Care Medicare and/or Medicaid preferred.
- Must be able to build and maintain collaborative, cooperative, and productive relationships both over the phone and face to face with all internal and external customers including members and their families, physicians, the health plan, vendors, and other health care providers as well as any other stakeholders in the community.
- Must be able to make assessments of individuals who suffer from multiple co-morbidities on an independent and regular basis both over the phone and face to face in the member’s home to determine their immediate need.
- Must be flexible and supportive of team members whether assigned work is telephonic or in the field.
- Computer skills necessary: email, electronic medical record management, Word, and Excel.
- Ability to meet and maintain necessary requirements per facility guidelines based on job assignment. These requirements may be outside the scope of Family Choice policies.