Care Coordinator/Case Management - RNs
Completes a face to face comprehensive assessment of the member's health and psychosocial needs.
Comprehensive assessments will be completed timely to meet contractual terms. Initial assessments must be completed within 60 days of admission to the nursing facility, annually, and when there is a significant change in condition.
Works in partnership with the interdisciplinary care team to develop a plan of care for member. Identifies patient goals and approaches, and updates as needed.
Ensures that plans of care are person centered, that the member and/or family is the primary decision maker and involved in the care plan process.
Strives to promote member self-advocacy and self-determination
Ensures that the services that the member receives are appropriate to meet their medical
Acts as an advocate for the member's health care needs.
Promotes education of medical health conditions. Ensures that the member and/or their caregiver are educated on managing their medical condition and comorbidities to help them attain set goals and improve medical outcomes.
Works collaboratively with direct care staff, the enrollee, the interdisciplinary team, physician(s), and the MCO Care Manager in the management of the members health needs.
Coordinates care services between the nursing facility and the managed care organization.
Promotes high quality outcomes and better utilization of long term care services.
Assists the member in the safe transitioning of care to the next most appropriate care level.
Ensures all mandatory training is completed on time.
Practices in accordance with applicable local, state, and federal laws which govern confidentiality and medical information privacy regulations (HIPAA).