- Engage with the enrollee in their homes and other community settings to establish an effective, complex care management relationship, while considering the cultural and linguistic needs of each member.
- Function as a liaison between healthcare providers, community resources, and enrollees to ensure seamless communication and care transitions.
- Perform required assessments on a timely basis, including but not limited to Comprehensive Assessment, MDS-HC (or successor) Functional Assessments, and Crisis and Risk Assessments
- Engage enrollees in care plan development and implementation, providing routine updates as the enrollee's status changes
- Lead the interdisciplinary care team (ICT) and collaborate with peers both internal and external to the organization, to create holistic care plans that address medical and non-medical needs.
- Oversee enrollee utilization of long-term services and supports, ensuring appropriate systems are in place for enrollees to remain in the location of their choice
- Assist members in accessing community resources, including housing, transportation, food assistance, and social services.
- Educate members about their benefits and available services under both Medicare and Medicaid.
- Provide education to members and their families about managing chronic conditions, medication adherence, and preventive care.
- Promote healthy lifestyle choices and self-management strategies.
- Assist enrollees in preventative health strategies, including gap closure
- Follow up with members after hospitalizations or significant health events to ensure continuity of care and prevent readmissions.
- Work closely with primary care physicians, specialists, and other healthcare providers to coordinate care and share relevant information.
- Coordinate with community-based organizations, other stakeholders/entities, state agencies, and other service providers to ensure coordination and avoid duplication of services.
- Advocate for the needs and preferences of enrollees within the healthcare system.
- Evaluate member satisfaction through open communication and monitoring of concerns or issues.
- Regular travel to conduct member, provider and community-based visits as required
- Report abuse, neglect, or exploitation of older adults and adults with disabilities as a mandated reporter as required by State law.
- Adherence to NCQA and Care Management standards
- Perform any other job related duties as requested.
Requirements
- Associates of Science (A.S) degree in nursing from an accredited nursing program required
- A Registered Nurse with the ability to independently serve people with complex medical, behavioral, and social needs. required
- Prior experience in care coordination, case management, or working with dual-eligible populations preferred
- Medicaid and/or Medicare managed care experience preferred
- Clinical Field/ Community Based Training a Plus
Core Competencies
Demonstrates expertise in care coordination and case management, with a strong focus on engaging enrollees in their care plans and addressing their medical and non-medical needs. Proficient in navigating Medicare and Medicaid systems while advocating for enrollees' preferences and ensuring continuity of care.
Highest-signal resume keywords
- Registered Nurse
- Care Coordination
- Case Management
- Medicaid Experience
- Medicare Experience
ATS Optimization Keywords
Hard Skills
- Comprehensive Assessment
- MDS-HC Functional Assessment
- Crisis Assessment
- Risk Assessment
- Chronic Condition Management
- Preventive Care Strategies
- Gap Closure Strategies
- Community Resource Access
- Health Education
- Utilization Management
Soft Skills
- Effective Communication
- Advocacy
- Interpersonal Skills
- Team Collaboration
- Cultural Competence
Certifications & Qualifications
- Associates of Science (A.S) in Nursing
Industry Keywords
- Dual-Eligible Populations
- Long-Term Services and Supports
- NCQA Standards
- Care Management Standards
- Community-Based Organizations