Client Caseload Management

• Coordinate care management in collaboration with the Mid-Level Practitioner (MLP).

• Ensure ICT meeting occur regularly and include the MLP, Provider Physician, RNCC, SNF staff and

administrators, beneficiaries, and families.

• Complete Health Risk Assessment within 30 days of enrollment for all new attributed members and update the HRA within 364 days of initial assessment.

• Triage care needs based on the member’s HRA scores and information from other sources.

Administrative duties

• Educate skilled nursing facilities’ staff through ICT meetings and regular communications while onsite.

• Provide in-service education to skilled nursing facilities’ staff relating to specific needs of the geriatric population including but not limited to polypharmacy, fall prevention, and wound care management.

• Identify and address changes in member’s health status by being available on call when not at the skilled nursing facility during scheduled visits.

• Participate in quality assurance initiatives as needed to contribute to the development and implementation of best practices.

• Advocate, inform, and educate members and their families through regular meetings and discussions.

• Maintain accurate and up-to date documentation in electronic health record regarding assessments, care plans, progress notes, and communications with family and patients.

• Participate in meetings to discuss quality metric goals and progress towards goals.

Education and/or certifications

• Registered Nurse Skills and Qualifications

• 2+ years’ experience in LTC/ALF setting

• Computer skills and proficiency in MS Office, PCC and Matrix required

• Experience in care coordination or case management is a plus

• Effective verbal and written communication skills

• Highly organized with confidential client material, appointment tracking and caseloads

• Strong customer service skills, knowledge of geriatric population and patient navigation

• Ability to work independently, deliver to deadlines, and effectively handle multiple priorities

• Ability to solve problems with minimal direction

• Great attention to detail and accuracy

• Interest in working with geriatric clients

• Knowledge of Chronic Conditions

• Knowledge of medications and their uses

• Develop a plan of care for each member in collaboration with the ICT team.

• Authorize and facilitate access to all covered services

• Provide clinical care to members to evaluate progress, conduct physical exams, prescribe interventions, and

communicate results to the SNF staff in concert with any other attending physicians or practitioners.

• Oversee transitions of care with communication from hospital, provider, family, and skilled nursing facility.

• Conduct follow-up assessments and ensure continuity of care post-discharge from hospital.

• Obtain labs, diagnostic reports and consultation reports and review as needed with plan medical director and ICT.

• Provide information and document decisions regarding Advance Directives.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.