Job Description

Responsible for conducting telephonic or face-to-face assessments for the identification, evaluation, coordination and management of Members’ needs, including physical health, behavioral health, social services and long term services and supports; develops the Member’s Individualized Service Plan to address those needs. Establishes relationships with referral sources and community resources, while maintaining strict member confidentiality and complying with all HIPAA requirements.

1. Responsible for identifying members with potential for high risk complications (such as nursing home admissions) and using knowledge in coordinating appropriate treatment in conjunction with the member and the health care team.

2. Responsible for managing members with chronic illnesses, co-morbidities, and/or disabilities, to insure cost effective and efficient utilization of health services. Seeks to coordinate creative solutions to members’ health care needs while optimizing efficiency and quality outcomes.

3. Obtains a thorough and accurate member history including physical, behavioral, social, biopsychosocial, and environmental factors, and collaborates with the member’s PCP or treating physician and specialists in the development of an Individual Service Plan.

4. Conducts ongoing member assessments to include implementation, coordination, monitoring and evaluation. Utilizes critical thinking skills and applicable managed care criteria to evaluate and identify needs for home and community-based services and/or skilled needs.

5. Establishes short and long term goals in collaboration with the member, caregivers, family, natural supports, physicians, etc. that meet the member’s needs; identifies members that would benefit from alternative level of care or other waiver programs and develops an Individual Service Plan based on member needs.

6. Reviews benefit options, acquires data and evaluates necessary services for appropriateness; documents effectiveness of service coordination activities.

7. Perform other duties as assigned.

Job Requirements

• Bachelors degree from an accredited college or university in Nursing, Social Work, Counseling, Special Education, Sociology, Psychology, Gerontology, or a closely related field, State Waiver (NM), or a minimum of six years of experience working for State agencies directly or by contract.

• Bachelors Degree in an unrelated field and at least two years of geriatric experience

• Minimum of two years of experience working with individuals with chronic illnesses, co-morbidities, and/or disabilities in a Service Coordinator, Case Management, Advocate or similar role.

• Experience in home health, health care, discharge planning, behavioral health, collaborating with nursing facilities, community resources, and/or other home and community-based agencies.

• Experience working with Medicare, Medicaid, and managed care programs.

• Must possess a valid driver’s license, motor vehicle insurance and access to a motor vehicle, or access to reliable public transportation within the service area.

• Additional state mandated certification, where appropriate.

Language Skills 

• Bilingual (ability to read, write, and speak) Spanish and/or Native American Language - STRONGLY PREFERRED.

CONTACT:

Jason Edwards

Nurse Resolutions

888.411.2228 x 200 - Toll Free

407.982.7508 - Fax

www.nurseresolutions.com



rn, registered nurse, lpn, licensed practical nurse, lsw, licensed social worker, service coordinator, case manager, case management, human services, medicaid, medicare, community health, discharge planning, social work, home health, geriatrics, bilingual, spanish, zuni, navajo, gallup, nm, native american