Source from Dallas, TX. Will be conducting in-home assessments 3-4 times/week. Job Description:Performs care management duties to assess and coordinate all aspects of medical and supporting services across the continuum of care for complex/high acuity populations with primary medical/physical health needs to promote quality, cost effective care. Develops a personalized care plan / service plan for long-term care members, addresses issues, and educates members and their families/caregivers on services and benefit options available to receive appropriate high-quality care.Education/Experience:Requires Graduate from an Accredited School or Nursing or a Bachelor's degree and 4-6 years of related experienceBachelor's degree in Nursing preferredLicense/Certification:RN - Registered Nurse - State Licensure and/or Compact State Licensure required orNP - Nurse Practitioner - Current State's Nurse Licensure requiredEvaluates the service needs of the most complex or high risk/high acuity members and recommends a plan for the best outcomeDevelops and continuously assesses ongoing long-term care plans / service plans and collaborates with care management team to identify providers, specialists, and/or community resources needed to address member's needsCoordinates and manages as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or servicesMonitors care plans / service plans and/or member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / needsMonitors member status for complications and clinical symptoms or other status changes, including assessment needs for potential entry into a higher level of care and/or waiver eligibility, as applicableReviews member data to identify trends and improve operating performance and quality care in accordance with state and federal regulationsReviews referrals information and intake assessments to develop appropriate care plans / service plansCollaborates with healthcare providers as appropriate to facilitate member services and/or treatments and determine a revised care plan for member if neededCollects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and clinical guidelinesProvides and/or facilitates education to long-term care members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefitsActs as liaison and member advocate between the member/family, physician, and facilities/agenciesEducates on and coordinates community resources. Provides coordination of service authorization to members and care managers for various services based on service assessment and plans (e.g., meals, employment, housing, foster care, transportation, activities for daily living)May perform home and/or other site visits (e.g., once a month or more), such as to assess member needs and collaborate with resources, as requiredPartners with leadership team to improve and enhance quality of care and service delivery for long-term care members in a cost-effective mannerMay precept clinical new hires by fostering and building core skills, coaching and facilitating their growth, and guiding through the onboarding process to upskill readinessMay provide guidance and support to clinical new hires/preceptees in navigating within a Managed Care Organization (MCO) and provides coaching and shadowing opportunities to bridge gap between classroom training and field practiceMay engage and assist New Hire/Preceptee during onboarding journey including responsibility for completing competency check points ensuring readiness for Service Coordination successEngages in a collaborative and ongoing process with People Leaders and cross functional teams to measure and monitor readinessPerforms other duties as assignedComplies with all policies and standards Walk me through the day to day responsibilities of this the role and a description of the project :
- Will conduct in home assessments 3-4 times a week to put in LTSS services
Describe the performance expectations/metrics for this individual and their team:
- Audit scores and Turn around times
Tell me about what their first day looks like:
- Getting assess to computer and assigned trainings
What previous job titles or background work will in this role? Any future projected positions potentially coming up? YES If yes, note: Internal/External Groups with which the Candidate will interface: Required Skills/Experience: Preferred Skills/ Experience: 1. RN 1. Critical care or bedside care 2. 2. 3. 3. Education Requirement: RN Education Preferred: Required Certifications: RN Is DFPS check required? Required Testing: Software Skills Required: