Care Manager

Job Title: Care Manager, RN – USC Only

Location: Position is for New Castle County and Sussex County, DE (open to candidates in either of these counties or within close proximity)

Face-to-face visits will be required. Must be willing to begin visits on week 1.

Must be willing to travel throughout the state (may only need to travel 2-3 times a week depending on schedule)

Responsibilities:

• Travel to members’ homes, nursing facilities, and other community based settings in order to complete face to face needs assessments with subsequent telephonic contact with the member in accordance with state and national guidelines, policies, procedures, and protocols.

• Assess, plan, coordinate, implement and evaluate care for eligible members with chronic and complex health care, social service and custodial needs in a nursing facility or home and community-based care setting.

• Coordinate care across the continuum of services and assisting members physical, behavioral, long term services and supports (LTSS), social, and psychosocial needs in the safest, least restrictive way possible while considering the most cost-effective way to address those needs.

• Facilitate authorization, coordination, continuity and appropriateness of care and services in community or HCBS.

• Facilitate transitions to alternate care settings such as hospital to home, nursing facility to community setting using an integrated care team to address the member’s specific needs.

Required Qualifications:

• Registered Nurse in the state of DE

• 5 years of Intensive Case Management and Discharge Planning experience

• Experience completing Assessments, developing Service Plans and Care Plans

• Experience collaborating with PCP’s, Occupational Therapists, Behavioral Health, and Providers

• Experience with ordering DME Equipment

• Experience educating and providing resources for the member’s Social Determinants. They must have experience with discharging members from a Facility setting.

• Working flexible hours to meet member’s needs

• Proficiency in PC-based word processing and database documentation (Word, Excel, Internet, Outlook) • Reliable transportation daily to be able to travel within assigned territory

• Ability to meet regulatory deadlines.

• Has a dedicated home work space used only for business purposes and is able to comply with all telecommuter policies.

• Experience in geriatric special needs, behavioral health, home health

• Understanding of the importance of cultural competency in addressing targeted populations.

Preferred Qualifications:

• Certified Case Manager (CCM)

• Licensed Bachelor’s Social Worker (LBSW)

• Licensed Master’s Social Worker (LMSW)

• Licensed Clinical Social Worker (LCSW)

• Experience working with HIV/AIDS population

• Experience working with behavioral health population

• Experience working with developmental disabilities population

• Medicare and Medicaid experience