Provides telephonic clinical care management services using evidence-based practices to ensure effective utilization of benefits, services, and care is provided to the patients allowing them to remain safely in their home/community.

$93,400.00 - $116,800.00 Annual

• Initiates conversations with the home care team regarding the potential need for Hospice and Palliative Care.
• Reviews VNS Health patient records for cases that were readmitted during an active home care episode.
• Identifies potential barriers to Hospice and Palliative Care; follows up with clinical operations to communicate identified barriers and recommended interventions, as appropriate.
• Participates in internal and external clinical case review meetings for select patient populations, as needed. Maintains excellent communication and relationships with home care and hospice teams.
• Reviews VNS Health patient records for cases that were readmitted during an active home care episode. Participates in the root cause analysis of the readmission event in collaboration with VNS Health operations and helps to develop recommendations for quality improvement measures.

Coordinates and/or oversees the coordination of benefits and services for all members on his/her caseload.

Completes care management and disease specific assessments.
Makes timely telephonic care management calls based on risk level.
Resolves and coordinates complex issues and member complaints impacting the delivery of services.
Provides health education to member/caregiver.
Assess SDoH and provide care coordination to reduce/remove barriers of care to include ability to allow for changing levels of care based on assessments, trigger events and program data/reports.
Identifies member safety issues and intervenes as necessary or refers to appropriate resources, such as community linkages, dietary, therapy (PT/OT/ST), HHA services, behavioral health, and DME.
Coordinates the delivery of high quality, cost-effective care based on a customized population model of care supported by evidence based clinical practice guidelines.
Advocates for the member/caregiver to obtain the health care and other services needed to optimize their quality of life.
Utilizes the Care Management process to set priorities, plan, organize and implement interventions that are goal directed towards self-care outcomes and the transition to independent status.
Promotes adherence to the physician treatment plan by providing education, coaching and support.
Educates, coordinates, and provides resources to reduce inappropriate utilization of emergency room (ER) and hospital service.
Increases utilization of primary care, specialty care, preventive health and guideline-based treatments including proper pharmacotherapy within network, as appropriate.
Participates in interdisciplinary team (IDT) meetings and provide input on customer service-related activities.
Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
Ensures compliance with payors' policies and procedures as well as all Federal and State regulations.
Interprets and implements VNS Health policies, state and federal regulations.
Participates in special projects and performs other duties as assigned.

Licenses and Certifications:
License and current registration to practice as a Registered Professional Nurse in NYS required
Population Care Coordination certification preferred
Care Management, Case Management, OASIS or other applicable certification preferred

Education:
Associate's Degree in nursing required or
Bachelor's Degree in Nursing from a program approved by the New York State Department of Education required

Work Experience:
Minimum two years of experience as a registered nurse required
Care management and/or managed care experience preferred
Proficiency in Microsoft Office applications required
Demonstrated analytical skills required