Care Manager - Nursing

JOB PURPOSE

Responsible for overall care management and quality of care for participants. Uses specialized discipline-specific knowledge to review assessments of field staff and coordinate a holistic care plan that addresses all domains of care. Provides care coordination in a manner that is sensitive to age, gender, sexual orientation, cultural, linguistic, racial, ethnic, religious backgrounds, and congenital or acquired disabilities.

• Participates and represents their discipline in the care planning meetings or as necessary.
• The Care Manager will review all discipline-specific documentation for quality and addresses any deficiencies with the field staff following disciplinary steps established by the Discipline Policy.
• Monitor how field staff is documenting all interventions with the participants and address/document any issue observed with the employee.
• Conduct coaching sessions with field staff as needed.
• The Care Manager (CM) communicates with the discipline-specific field staff regularly to coordinate a continuum of care consistent with the Member’s health care needs and goals. This care plan supports the Member in attaining and maintaining an optimal functional and health status.
• In coordination with the IDT, arranges, coordinates, and authorises the provisions of appropriate services to meet identified member-specific needs (such as assistance with the Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), housing, home-delivered meals, and transportation) and when approved by the IDT, may authorise a range and number of community-based services.
• Implements specific care management activities and interventions that lead to accomplishing the participant’s goals.
• Provides care management services across sites and collaborates with appropriate team members, facility, discharge planner, and home care coordinator when members are transitioned between care settings.
• Documents services in accordance with CLHC standards and federal/state regulations.
• Coordinates, facilitates, and arranges for long-term care services in nursing homes, rehab facilities, etc. as needed.
• Collaborates with PCP and other Specialty physicians and specialty-based services and members of IDT regarding any changes in participant’s condition to secure, arrange and coordinate all resources for implementing optimal care.
• Provides or arranges for ongoing Skilled services, service authorisation, and periodic assessment reassessment and evaluation of services.
• Monitors care management activities, services, and members’ responses to interventions, to determine the effectiveness of the plan of care and the utilisation of services and implements changes and adjustments to meet needs and resolve goals.
• Evaluates the effectiveness of the plan of care in reaching desired goals and outcomes, makes modifications or changes in the plan of care based on changes in the member’s health, as needed.
• Fiscally responsible for providing services based on members’ needs.
• Maintains up-to-date knowledge about current health-related issues, procedures, evidence-based clinical practice guidelines, medications, and impacting health and practice standards.
• Conduct competencies, and training sessions with field staff as needed.
• Recommends and contributes to improvements in services, programs, policies, and procedures to ensure optimum care and services to members.
• Follows the organization’s policies regarding disciplinary action. Engages Human Resources as needed for guidance on disciplinary actions and terminations.
• Only act within the scope of the individual’s authority to practice.
• Meet a standardized set of competencies for the specific position description established by the PACE organization before…