Nurse Care Manager, Assessment

Senior Whole Health
New York, NY
Oct 08, 2017
Jobs Outside Higher Education
Other Jobs Outside Higher Education
Institution Type
Outside Academe

Job Description

LANGUAGE REQUIREMENTS: Bengali OR Haitian Creole OR Spanish OR Mandarin and Cantonese

MUST BE WILLING TO TRAVEL TO Brooklyn OR Manhattan OR Bronx OR Queens

Position Summary:

The Assessment Nurse works in collaboration with the member's Nurse Care Manager (NCM) and an interdisciplinary team to assess members with complex medical, behavioral and psychosocial needs. The Assessment Nurse coordinates and facilitates development, implementation and monitoring of Individual Care Plans (ICP)/Person Centered Service Plan (PCSP) based on a member's goals, preferences and disease states. The goal of the ICP/PCSP is to link members to appropriate care, services, and community resources, promote self management in order to improve the health status, functioning, community integration and quality of life for SWH members in their preferred place of residence.

Essential Functions/Responsibilities:
  • Conduct face to face and telephonic assessments of members' functional status, medical, behavioral, psychosocial and community resource needs.
  • Provides the Interdisciplinary Care Team (ICT) with assessment information and act as facilitator to ensure that members' needs are met.
  • Develop an ICP/PCSP based on members' clinical, behavioral and social needs that addresses barriers to care.
  • Competently assesses members' health status and ensures that member is receiving all necessary medical and supportive services
  • Modify ICP/PCSP as appropriate to member's needs and progress
  • Manage care transitions through effective and timely communication necessary for member care and discharge planning.
  • Clarifies SWH plan medical benefits, policies and procedures for members, providers and community based agencies.
  • Prepare for and participate in clinical case reviews to share best practices.
  • Adhere to SWH documentation policies and procedures including documentation of clinical assessment activities and their effectiveness.
  • Maintain a comprehensive working knowledge of community resources, payer requirements, and network services for target population
  • Collaborate with other SWH Care Managers to reduce variations in clinical practice, identify opportunities for systems' improvement, and develop policies and procedures relevant to practice.
  • Provide backup to other Assessment nurses as needed
  • Analyze data and use it to improve care delivery
  • Performs other duties as assigned.

  • Must possess UAS experience
  • Previous home healthcare/field experience is strongly preferred
  • Candidate must be a Registered Nurse licensed in appropriate State
  • Must possess valid driver's license and/or reliable transportation for community travel

  • Knowledge of Medicare and Medicaid programs an advantage
  • Knowledge of chronic disease management

  • Minimum of 2 years of current clinical nursing experience with home care, case management, or recent acute care experience
  • Medicare/Medicaid managed care experience preferred
  • Experience working with a geriatric population or equivalent experience preferred

  • Strong professional level of knowledge and comprehensive clinical assessment skills in the adult population and chronic disease management
  • Excellent communication skills
  • Strong computer skills: competent in Microsoft Office Products (Outlook, Word, Excel)
  • Ability to work independently and maintain flexibly in fast paced environment
  • Ability to analyze data and use it to improve care delivery
  • Self starter with high level of accountability and responsibility for outcome of care
  • Highly organized and able to manage multiple priorities appropriately
  • Independent problem solving skills
  • Able to work collaboratively and build enduring relationships with providers, members and the multidisciplinary team

Working Conditions:

Minimum of 90% travel within service area

Company Description
Since enrolling its first member in Massachusetts in 2004, Senior Whole Health (SWH) has led the way as an affordable and innovative health care plan for "dual-eligible" people who qualify for both Medicare and Medicaid. Senior Whole Health is both an approved Medicare Special Needs Plan (SNP) and a Medicare Part D Plan. Available in Massachusetts and New York, Senior Whole Health provides members with better experiences through personal care management and comprehensive benefits.

Senior Whole Health's vision is to be a national leader in integrated health care that is simple, comprehensive, humane and respectful of its members.

Senior Whole Health's mission is to maximize our members' quality of life, health, security and independence by offering a voluntary health care plan that's simple to join, provides security and peace of mind through support and advocacy, and helps members live as independently as possible through comprehensive, community-based support and services.

New York, NY


Sat, 7 Oct 2017 12:19:10 PDT