RN Case Manager

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms. Even in a non-clinical role, Elderplan employees have an opportunity to make a positive impact on the quality of our health plan members' lives.

Provides telephonic assessments of members identified as high risk for incurring hospitalizations or high dollar/high volume procedures, through in-house referrals, health risk assessments, data mining, PCP referrals or member requests. Utilizes pre-determined assessments, workflows, standards of care, educational tools, and Medicare guidance to evaluate member's clinical status, assess self-care/knowledge deficits, and to develop a plan of care to educate the member/member's representative to achieve independence in self-care. Monitors the plan of care and re-evaluates when goals are not met. Utilizes in-network providers, community based resources, and inter-agency programs (such as Hospice, Palliative care) when necessary. Uses discharge parameters to determine program discharge readiness. The Case Manager follows all workflows for pre-determined interventions for the Chronic Care Improvement Program, Quality Improvement Program, and Medication Therapy Management Programs as needed.

• Bachelor's degree in nursing (BSN) preferred; Associates degree accepted with extensive case management experience
• 3-5 years of case management experience in a health care setting, preferably managed care setting.
  Working knowledge of utilization management, case management, Medicare/Medicaid regulations. Specialized Knowledge and Skills, License/Certification
• NYS RN license and registration.
• Excellent knowledge of computer software programs including case management software and/or electronic medical records.
• Excellent customer service, verbal communication, writing, and presentation skills.
• Ability to demonstrate effective critical thinking and problem-solving skills.
• Excellent interpersonal skills.
• Knowledgeable in case management processes in managed care setting
• Knowledge of Federal and State regulations, managed care regulations, and concepts
• Ability to provide appropriate support and direction to facilitate collaborative efforts toward accomplishing established goals and objectives.