Position Summary: Responsible for delivery of care management in the long-term care and community setting as delegated in subcontracts with health plans which are contracted with CMS and DHS. Follow and uphold the Mission of Genevive.

Hours per Pay Period: 80hrs Classification: Full-Time Exempt

Education/Qualifications:

• Must be a Licensed Registered Nurse or Licensed Social Worker (LSW, BSW, or MSW)
• Must have the appropriate state license
• Experience working in Geriatrics
• Exceptional professional communication and organization skills
• Bachelor’s degree in nursing, social work, or closely related field with 1 year of home and community-based experience
• Associate degree in nursing with 2 years of home and community-based experience
• Knowledge of Medicare, Medical Assistance and Federal Waiver programs
• Knowledge of geriatric population and special care needs
• Knowledge of community services organizations, agencies, programs and funding sources
• Must be willing to work with ethnically diverse populations
• Good computer skills with specific knowledge of Microsoft Office program
• Willing to work independently from a home office as well as function as a team member

• Provides comprehensive assessment or screening of each member’s social, medical and environmental safety needs. Documents results in a timely manner on appropriate forms
• Conducts visits in person and by telephone on a timely basis
• Performs review of medical records in the appropriate EMR
• Develops Person Centered Plans of Care based on assessment maximizing the level of self-determination and member choice of services, service providers and living arrangements to meet identified needs. This includes disease management, advance directive planning, and vaccination updates.
• Incorporates interdisciplinary/holistic and preventive care across all settings of care per CMS timeline.
• Provides culturally appropriate care
• Communicates care needs and plan of care with member and/or member representative, primary physicians and interdisciplinary team members through written and/or verbal communication
• Contacts appropriate personnel in hospital, nursing facility, foster care or assisted living settings to share and obtain necessary information that will facilitate discharge of the member to the appropriate level of care
• Communicates with service providers and members while assisting with arrangement and authorization of services and issue denials of inappropriate services in a timely manner
• Interdisciplinary collaboration with population health team when members have complex medical needs.

Physical/Mental Demands and Work Environment:

• Requires sitting and standing associated with a normal office environment.
• Requires the use of office equipment, such as copiers, computers, telephones and fax machines.
• Work requires hand dexterity for office machine operation, stooping and bending to files and supplies, mobility to complete patient visits, or sitting for extended periods of time.
• Able to handle stress in dealing with tense, angry, and/or upset clients or patients.
• Must be able to prioritize activities when faced with competing demands.
• Must be able to lift 25 lbs. occasionally, 10 lbs. frequently.
• Use of personal vehicle. Vehicle must be reliable and have proof of insurance. Employee must have a valid driver’s license.
• HIPAA compliant home office environment
• Contact with staff and physicians.
• Frequent contact with patients in their homes and Nursing Home.
• Some exposure to communicable diseases.

Current caseload is located in the south metro area: Minneapolis, St. Paul, Eagan