Care Manager – Registered Nurse (RN) or
Licensed Master Social Worker (LMSW) - Bilingual Spanish!
New York, NY
Premier Home Health Care Services, Inc. is a leading established Home Health Care Agency. We currently have an opportunity for a Care Manager in our NYC mid-town office. Possible telecommuting potential.
The Care Manager provides clinical support and oversight of care that ensure members are receiving safe and effective care in the community.
Key functions include:
• Responsible for service authorizations, creates care plans, and coordinates services throughout the continuum of care for high-risk populations.
• Assesses and coordinates Hospitalization / Skilled Services CHHA /Nursing Home Communication and Planning.
• Coordination of Benefits for Medicare, Medicaid, Other insurance.
• Coordinates transitional care management (acute to home, home to skilled nursing facility SNF/custodial, home to hospital and acute to SNF/custodial.
• Completes Monthly Call Assessments and follows up on calls triggered by changes in meds, diagnosis or events such as ER visits, falls, etc.
• Coordinates post-discharge services as needed.
• Conducts managed long-term care quality measure planning and implements evidence based clinical pathways.
• Collaborates with Clinical Consultant Team on issues requiring additional psychosocial and clinical guidance for complex member needs. Examples include end of life care planning, acute condition management, completion of POA, health proxy, or guardianship documentation.
• Documents all findings and interventions.
• Participates as team member in Biannual Reassessments of Service Plans after UAS Completion.
• Member Education and Management of CDPAS Services and Health Care Proxy.
• Member PCA Service Review and Management.