Job Description

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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