Care Manager, RN – CW

SriMatrix health; New Castle (DE); Hybrid; USD 75,000 - 95,000; Full time

Job summary

SriMatrix health in New Castle, DE, seeks a contracted Home Health Case Manager RN to travel statewide for face-to-face needs assessments and telephonic follow-ups, coordinating care across LTSS, behavioral health, and social services.

You will develop plans of care, collaborate with clinicians and discharge planners, document in EHR, and ensure compliance with HIPAA and regulatory standards. This role requires strong organization and flexible hours.

Qualifications

• DE RN licensure with case management experience.
• Experience completing Assessments, Service Plans and Care Plans.
• Experience collaborating with PCPs, OT, Behavioral Health and Providers.
• Experience with ordering DME Equipment.
• Experience educating members on Social Determinants and resources.
• Experience discharging members from facility settings.
• Willingness to travel 2–3 times per week across the state.
• Proficiency in Word processing and database documentation.
• Ability to meet regulatory deadlines and maintain privacy (HIPAA).
• Geriatric, behavioral health, and home health experience.
• Cultural competency in addressing diverse populations.
• Experience with electronic documentation systems.
• Experience with cost neutrality and budgeting.
• Very organized and able to manage multiple cases.

Responsibilities

• Travel to members' homes and other sites to conduct face-to-face needs assessments.
• Coordinate care across LTSS, social services, and community resources.
• Facilitate transitions from hospital to home and other settings using an integrated care team.
• Develop care plans with members or caregivers and identify required services.
• Collaborate with healthcare team to coordinate resources and referrals.
• Ensure services align with plan of care and regulatory requirements.
• Document all case management activities in the EHR per HIPAA and company policy.
• Perform additional duties as needed.

Skills

RN License (DE)

Case Management

Assessments & Care Plans

Care Coordination

DME Ordering

Social Determinants Resources

Discharge Planning

Regulatory Compliance

Strong Organization

Telephonic Assessments

Cultural Competency

Electronic Documentation

Budgeting & Cost Neutrality

Travel in State

Communication Skills

Time Management

Tools

Word

Excel

Internet

Outlook

Job description

Location: New Castle, DE

Duration: 3+ Months

Job Type: Contract

Work Type: Hybrid

Responsibilities

• Travel to members’ homes (occasionally a hospital or motel and very rarely a long-term care facility or nursing home) 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.
• 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.
• 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

Required Qualifications

• Registered Nurse in the state of DE, with case management 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)
• Ability to meet regulatory deadlines.
• Has a dedicated homework 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

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