Mobile Health Team LLC
RN Care Manager
Mobile Health Team LLC, Wilmington, Delaware, us, 19894
Responsibilities:
Travel to members’ homes, nursing facilities, and other community-based settings 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 assist 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 make appropriate revisions as needed in accordance with 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 interventions 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
5 years of Intensive Case Management and Discharge Planning experience.
Experience completing Assessments, developing Service Plans and Care Plans.
Experience collaborating with PCPs, Occupational Therapists, Behavioral Health, and Providers
Experience with ordering DME Equipment
Experience in geriatric special needs, behavioral health, home health
Experience educating and providing resources for the member’s Social Determinants.
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 workspace used only for business purposes and is able to comply with all telecommuter policies.
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
Important Qualifications: (any certification available is valid)
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 the behavioral health population
Experience working with the developmental disabilities population
Medicare and Medicaid experience
Job Type:
Full-time
Pay:
$40.00 - $43.00 per hour
Expected hours:
40 per week
Benefits:
401(k)
401(k) matching
Dental insurance
Health insurance
Life insurance
Paid time off
Vision insurance
Medical Specialty:
Geriatrics
Home Health
Schedule:
8 hour shift
Day shift
Monday to Friday
Experience:
Nursing: 5 years (Required)
Case management: 5 years (Required)
Discharge planning: 5 years (Required)
License/Certification:
RN (Required)
Work Location:
On the road
#J-18808-Ljbffr
Travel to members’ homes, nursing facilities, and other community-based settings 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 assist 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 make appropriate revisions as needed in accordance with 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 interventions 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
5 years of Intensive Case Management and Discharge Planning experience.
Experience completing Assessments, developing Service Plans and Care Plans.
Experience collaborating with PCPs, Occupational Therapists, Behavioral Health, and Providers
Experience with ordering DME Equipment
Experience in geriatric special needs, behavioral health, home health
Experience educating and providing resources for the member’s Social Determinants.
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 workspace used only for business purposes and is able to comply with all telecommuter policies.
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
Important Qualifications: (any certification available is valid)
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 the behavioral health population
Experience working with the developmental disabilities population
Medicare and Medicaid experience
Job Type:
Full-time
Pay:
$40.00 - $43.00 per hour
Expected hours:
40 per week
Benefits:
401(k)
401(k) matching
Dental insurance
Health insurance
Life insurance
Paid time off
Vision insurance
Medical Specialty:
Geriatrics
Home Health
Schedule:
8 hour shift
Day shift
Monday to Friday
Experience:
Nursing: 5 years (Required)
Case management: 5 years (Required)
Discharge planning: 5 years (Required)
License/Certification:
RN (Required)
Work Location:
On the road
#J-18808-Ljbffr