Client Caseload Management
- Coordinate care management in collaboration with the Mid-Level Practitioner (MLP).
- Ensure ICT meeting occur regularly and include the MLP, Provider Physician, RNCC, SNF staff and
administrators, beneficiaries, and families.
- Complete Health Risk Assessment within 30 days of enrollment for all new attributed members and update the HRA within 364 days of initial assessment.
- Triage care needs based on the member's HRA scores and information from other sources.
Administrative duties
- Educate skilled nursing facilities' staff through ICT meetings and regular communications while onsite.
- Provide in-service education to skilled nursing facilities' staff relating to specific needs of the geriatric population including but not limited to polypharmacy, fall prevention, and wound care management.
- Identify and address changes in member's health status by being available on call when not at the skilled nursing facility during scheduled visits.
- Participate in quality assurance initiatives as needed to contribute to the development and implementation of best practices.
- Advocate, inform, and educate members and their families through regular meetings and discussions.
- Maintain accurate and up-to date documentation in electronic health record regarding assessments, care plans, progress notes, and communications with family and patients.
- Participate in meetings to discuss quality metric goals and progress towards goals.
Education and / or certifications
- Registered Nurse Skills and Qualifications
- 2+ years' experience in LTC / ALF setting
- Computer skills and proficiency in MS Office, PCC and Matrix required
- Experience in care coordination or case management is a plus
- Effective verbal and written communication skills
- Highly organized with confidential client material, appointment tracking and caseloads
- Strong customer service skills, knowledge of geriatric population and patient navigation
- Ability to work independently, deliver to deadlines, and effectively handle multiple priorities
- Ability to solve problems with minimal direction
- Great attention to detail and accuracy
- Interest in working with geriatric clients
- Knowledge of Chronic Conditions
- Knowledge of medications and their uses
- Develop a plan of care for each member in collaboration with the ICT team.
- Authorize and facilitate access to all covered services
- Provide clinical care to members to evaluate progress, conduct physical exams, prescribe interventions, and
communicate results to the SNF staff in concert with any other attending physicians or practitioners.
- Oversee transitions of care with communication from hospital, provider, family, and skilled nursing facility.
- Conduct follow-up assessments and ensure continuity of care post-discharge from hospital.
- Obtain labs, diagnostic reports and consultation reports and review as needed with plan medical director and ICT.
- Provide information and document decisions regarding Advance Directives.
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