Clinical Care Manager (RN) -- CMO

What We Provide

What You Will Do

• Coordinates and/or oversees the coordination of benefits and services for all members on his/her caseload.
• Completes care management and disease specific assessments.
• Makes timely telephonic care management calls based on risk level.
• Resolves and coordinates complex issues and member complaints impacting the delivery of services.
• Provides health education to member/caregiver.
• Assess SDoH and provide care coordination to reduce/remove barriers of care to include ability to allow for changing levels of care based on assessments, trigger events and program data/reports.
• Identifies member safety issues and intervenes as necessary or refers to appropriate resources, such as community linkages, dietary, therapy (PT/OT/ST), HHA services, behavioral health, and DME.
• Coordinates the delivery of high quality, cost-effective care based on a customized population model of care supported by evidence based clinical practice guidelines.
• Advocates for the member/caregiver to obtain the health care and other services needed to optimize their quality of life.
• Utilizes the Care Management process to set priorities, plan, organize and implement interventions that are goal directed towards self-care outcomes and the transition to independent status.
• Promotes adherence to the physician treatment plan by providing education, coaching and support.
• Educates, coordinates, and provides resources to reduce inappropriate utilization of emergency room (ER) and hospital service.
• Increases utilization of primary care, specialty care, preventive health and guideline-based treatments including proper pharmacotherapy within network, as appropriate.
• Participates in interdisciplinary team (IDT) meetings and provide input on customer service-related activities.
• Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
• Ensures compliance with payors' policies and procedures as well as all Federal and State regulations.
• Interprets and implements VNS Health policies, state and federal regulations.
• Participates in special projects and performs other duties as assigned.

Licenses and Certifications:

• License and current registration to practice as a Registered Professional Nurse in NYS required or
• New York State License and current registration in Physical Therapy required or
• New York State License and current registration in Occupational Therapy required
• Certified Case Manager - Commission for Case Manager Certification within 1 year of employment required

Education:

• Associate's Degree in nursing required or
• Bachelor's Degree in Physical Therapy from a program approved by the New York State Department of Education required
• Bachelor's Degree in nursing preferred

Work Experience:

• Minimum two years of experience in health related field required
• Care management and/or managed care experience preferred
• Proficiency in Microsoft Office applications required
• Demonstrated analytical skills required