Care Manager - RN

SGS Consulting; Delaware (OH); On-site; USD 65,000 - 90,000; Full time

Job summary

SGS Consulting is seeking a dedicated Registered Nurse with extensive experience in intensive case management to deliver face-to-face assessments in members’ homes and community settings. You will coordinate complex care plans, support transitions, and educate members on available benefits and services in a travel-heavy role.

The role requires collaboration with primary care, behavioral health, and discharge planning teams, traveling within the assigned Delaware territory, and documenting all

Qualifications

• RN license in Delaware state
• 5 years of intensive case management and discharge planning
• Experience in assessments, service plans, and care plans
• Collaboration with PCPs, therapists, behavioral health, and providers
• Experience with DME equipment is preferred
• Experience with social determinants and discharging from facilities
• Excellent organization and ability to travel within territory

Responsibilities

• Travel to members’ homes, facilities and community settings for face-to-face assessments and telephonic follow-up.
• Assess, plan, coordinate, implement and evaluate care for members with complex needs.
• Coordinate care across LTSS, social and psychosocial supports.
• Facilitate authorization and continuity of care in community or HCBS.
• Support transitions from hospital to home or facility to community.
• Educate members and caregivers on benefits, resources and long-term care options.
• Develop and adjust plans of care with members and caregivers.
• Identify resources for integrated care and referrals to specialized programs.
• Collaborate with care teams to address member needs and gaps in coverage.
• Document services in EHR, complying with HIPAA and policy requirements.

Skills

Care Manager

RN

Registered Nurse

Case Management

CCM

LBSW

LMSW

LCSW

Education

Registered Nurse in DE

Tools

PC-based word processing

Job description

Job 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.


• Educate members or caregivers regarding health care needs, available benefits, resources and services including available options for long term care community or facility-based service delivery.


• Provide education, resources, and assistance to help members achieve goals as outlined in their plan of care and to overcome obstacles to achieving optimal care in the least restrictive environment.


• Develop a plan of care in conjunction with members or caregivers to identify services to meet the member’s specific needs, and goals.


• Identify resources needed for a fully integrated care coordination approach including facilitating referrals to special programs such as Disease/Chronic Condition Management, Behavioral Health, and Complex Case Management.


• Collaborate with the member's health care and service delivery team including the DSHP Plus LTSS Member Advocate, ICT, and discharge planners, to coordinate the care needs and community resources for the member in order to maintain the member in the least restrictive safe environment possible. Assist members in developing, implementing and amending a back-up plan for gaps in provider coverage.


• Ensure approved support services are being provided as outlined in the plan of care. Evaluate the effectiveness of the service plan and making appropriate revisions as needed in accordance with per policy & procedures and state contractual requirements.


• Assist members in overcoming obstacles to optimal care through connection with community resources, including communicating with providers and formulating an appropriate action plan.


• Document all case management services and intervention in the electronic health record. Adhere to all company, State and Federal requirements related to privacy practices, HIPAA, and quality performance standards.


• Perform other duties as assigned/requested.

Skills:

• Care Manager, RN, Registered Nurse, Case Management, CCM, LBSW, LMSW, LCSW

Education/Experience:

• 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.


• Experience with electronic documentation system(s)


• Experience with cost neutrality and budgeting


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


• Must be able to communicate clearly to members - will be tasked with conducting assessments with members over the phone


• Must be very organized