Nurse Care Manager-NCQA Focus/NY License Required - (Remote)

Summary of Job 

Provide care management, as part of a multi-disciplinary care team, that includes care coordination, performing telephonic or face-to-face assessments of members’ health care needs, identifying gaps in care and needed support, administering/coordinating implementation of interventions.  Support and enable members to manage their physical, environmental and psycho-social concerns, understand and appropriately utilize their health plan benefits and remain safe and independent in their home or current living environment in collaboration with health care providers.  Provide Care Management services to identified high risk members within the community, including but not limited to Physician Practices, Retail Centers/Neighborhood Care Centers, and members’ homes.  Coordinate and provide care that is safe, timely, effective, efficient and member-centered to support population health, transitions of care, and complex care management initiatives.  Engage with the most complex members of the health plan with the goal of improving health care outcomes and appropriate and timely utilization of services across the continuum of care.  Assist the entire Care Management interdisciplinary team in managing members with Care Management needs.

Responsibilities 

• Assess and evaluate the needs of our most complex members, acting as the clinical coordinator collaborating with members, caregivers, providers, multi-disciplinary team, and health care and community resources through a variety of assessments to identify areas of (medical, financial, environmental, health insurance benefit, psycho-social, caregiving) concerns and potential gaps in care utilizing the most appropriate resources to support members’ needs.
• Identify appropriate goals, strategies and interventions that may include referrals, health education, activation of community-based resources, life planning, or program/agency referrals based on areas of concern.
• Develop, communicate and evaluate medical management strategies and interventions including potential for alternative solutions to ensure high quality, cost effective continuum of care with the member, caregiver, provider(s) and multidisciplinary team.
• Include member and family as appropriate.
• Engage actively with the member PCP / designee.
• Engage with the member in support of their treatment team to identify and establish attainable goals that positively impact clinical, financial, and quality of life outcomes for member.
• Work collaboratively with all stake holders to ensure knowledge of the action plan, including participation in telephonic and face-to-face case conferences when appropriate.
• Assess the needs of members and align them with the appropriate member of the care team (wellness team, registered dietitian, social worker, community health workers).
• Act as the member’s advocate and liaison by completing or facilitating interventions with providers and/or private, non-profit, and governmental agencies.
• Ensure that all Care Management processes and reporting are compliant with all applicable federal and state regulations, and NCQA and company standards.
• Participate in delegation collaboration activities, as required.
• Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making care management recommendations.
• Enter and maintain documentation in the Electronic Medical Records System (EMR), meeting defined timeframes and performance standards.
  Maintain an understanding of Care Management principles, program objectives and design, implementation, management, monitoring, and reporting.
• Actively participate on assigned committees.
• Attend and complete all department-mandated training as well as satisfy educational in-service requirements.
• Perform other related projects and duties as assigned.
• Provide ongoing monitoring, evaluation, support and guidance to the coordination of the member's health care.
• Develop, implement and coordinate plan of care and facilitate members’ goals.
• Coordinate interdisciplinary team tasks and activities, with the goal of maintaining team performance and high morale.