Duties/Responsibilities:

• Provides onsite and telephonic care management to support the members care needs to promote positive health outcomes

• Applies care management principles by advocating, informing, and educating beneficiaries on services, self-management techniques, and health benefits related to the continuum of care

• Reviews discharge planning, assessments, medical records, and screening for members recently discharged from inpatient facilities to ensure a safe and successful transition

• Assesses need for home care, out of home placement, and/or community-based services

• Develops care plans that align with the providers treatment plans and recommends interventions that align with proposed goals

• Completes assessments to identify barriers and opportunities for intervention

• Generates referrals to providers, community-based resources, and appropriate services and other resources to assist in goal achievement and maintenance of successful health outcomes

• Liaise between service providers such as doctors, social workers, discharge planners, and community-based providers to ensure care is coordinated and care needs are adequately addressed

• Coordinates and facilitates with the multi-disciplinary health care team as necessary in order to ensure care needs are addressed within members care plans and treatment is person-centered

• Discuss opportunities for developing and executing discharge plans with hospital and HF leadership

• Evaluates treatment to ensure alignment and execution of the members care and physician treatment plan

• Assists in identifying opportunities for alternative care options based on member needs, treatment history and member preferences

• Contributes to corporate goals through ongoing execution of member care plans and member goal achievement and successful coordination with local supports

• Documents all encounters with providers, members, and vendors in the appropriate system in accordance with internal and established documentation procedures; follows up as needed; and updates care plans based on member needs, as appropriate

• Occasional overtime as necessary

• Additional duties as assigned

Minimum Qualifications:

• NYS RN, LMSW, or LCSW

• Ability to travel around downstate New York which includes; the 5 boroughs, Long Island, and Westchester

Preferred Qualifications:

• Strong interpersonal and assessment skills, especially the ability to relate well with seniors, their families, and community care providers, along with demonstrated ability to handle rapidly changing crisis situations

• Experience in hospital/facility discharge planning

• Bilingual in Spanish, Korean, Mandarin, or Cantonese

• Knowledge and experience with the current community health practices for the frail adult population and cognitive impaired seniors

• Experience managing member information in a shared network environment using paperless database modules and archival systems

• Experience and knowledge of the relevant product line

• Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

• Proficient with simultaneously navigating the Internet and multi-tasking with multiple electronic documentation systems

• Experience usingMicrosoft Excel with the ability to edit, search, sort/filter and analyze data

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.