Registered Nurse-Care Manager

As a Registered Nurse-Care Manager, Axzons Home Healthcare expects that patients be provided with assistance in daily living and personal care services in their home in accordance with an established care plan.

General Purpose / Scope :

Under the direction of the Care Management Supervisor, the Care Manager is responsible for ongoing assessment of health, environmental, and psychosocial status of members assigned to him / her, six (6) month reassessments using the designated New York State Assessment tool, other plan assessment tools, and ongoing care management of patients through telephonic and in home contact.

Responsibilities of the Care Manager

• Provides care management including care planning, coordination, and assessment of health, environmental, and psycho-social status members on an ongoing basis. These assessments will be conducted in telephonically and in home visits;
• Monitoring services for quality, effectiveness, and progress toward goals;
• Coordination of transitions including discharge planning from the hospital or nursing home;
• Identifies health, environmental, and psycho-social risks for assigned members and recommends appropriate interventions to the Interdisciplinary Care team;
• Provides ongoing assessment of the effectiveness of the Patient's plan of care and discusses and develops a comprehensive Plan of Care in collaboration with the member, family, physician, and other interdisciplinary team members as appropriate by assessing and identifying the clinical, psycho-social and financial needs of the patient / family caregivers. Establish mutually agreed upon goals utilizing evidence based guidelines as available;
• Review member requests for services and supplies, using clinical criteria and provides rational for decision based on clinical criteria, in collaboration with Care Management Supervisor;
• Conducts semiannual reassessments using New York State assessment tool and other plan defined assessment tools;
• Coordinates services that are covered and not covered to create a comprehensive care plan that meets the medical, psycho-social and financial needs of the member;
• Requests disease management and condition specific plans for member's primary care practitioners and helps facilitate implementation.
• Implements disease management protocols as directed by the Care Management Supervisor and Patient Services Manager;
• Works collaboratively with the Interdisciplinary Care Team;
• Documents care management;
• Performs other job-related duties as may be required or directed by the supervisor.

Requirements : RN License :

Experience :

Core Competencies :

Job Types :