Serves as an overall case navigator for MLTC members, coordinating a continuum of care for all medical and social service needs, performing duties in an in-home setting 80% of the time. Acts as an Ambassador to the EmblemHealth brand and to “What Care Feels Like”. Achieves optimal benefit and results from the comprehensive management of members with chronic and/or catastrophic illness, members who are frail elderly and/or members whose illness is complicated by challenging psychosocial conditions. Provides global, episodic, specialized or complex case management and utilization management, as needed to ensure coordination of health care delivery, member education, and preventative intervention. Facilitates the coordination of all social and community services for members. Coordinates care in a variety of settings and provides focus on transition activities to benefit clinical needs of members.
• Assesses identified members face to face, within mandated timeframes, to determine members appropriate for case management early in their disease process or at any time during the continuum of care.
• Develops, facilitates, and communicates a plan of care in partnership with the member, his/her significant other, primary caregiver, the primary and attending physicians, and various providers.
• Optimizes both the quality of care and the quality of life for the member. Identifies members appropriate for specialty programs.
• Provides case management throughout the duration of the case including assessment, planning, implementation, coordination, monitoring, and evaluation to ensure member receives services and supports required to meet psychosocial, educational, health care and social service needs.
• Assists members and their families with the coordination of services from various settings, including clinical, social and community related as appropriate. Includes facilitation of discharge from acute setting to home and acute setting to alternate settings, and coordination of all needs of member including but not limited to medical billing, food service, financial planning, home care and home repair assistance. Provides Care Coordination throughout the continuum of care.
• Complete thorough case documentation as per established policy and procedure.
• Performs other duties as assigned or required. Regular attendance is an essential function of the job.
Position Success Criteria:
• Effectively able to assess, screen and stratify members who are appropriate for case management services.
• Able to manage a caseload of members who are in need of case management and able to apply the case
management process as outlined by the CMSA standards and EH policies.
• Make appropriate referrals to both internal and external clinical and social service related programs that meet the member’s needs.
• Ability to create and execute case management care plans and document per EH policies and procedures.
• Ability to speak professionally with all necessary parties associated with the member’s care plan.
Education and Experience:
• Registered Nurse
• Graduate of a 2- 4 year accredited nursing program; advanced degree preferred.
• Current, unencumbered license to practice professional nursing in the appropriate state.
• Minimum of 4 – 6 years clinical nursing experience in acute high-tech or home health setting.
• Must possess a valid driver’s license, motor vehicle insurance and access to a motor vehicle, or access to reliable public transportation within the appropriate service area.
• Proficient in the use of Microsoft office tools.
• Certification as a Case Manager preferred.
• Prior case management and/or managed long term care experience strongly preferred.
Group Health Incorporated (GHI) - 18 months ago
EmblemHealth is set on being the mark of good health in the Northeast. The not-for-profit company provides health...