Develops and updates individualized care plan based on comprehensive assessment of members in
consultation with the member and family/caregiver and the assessment nurse
Implements the care plan and authorizes/arranges for delivery of covered services consistent with the
Conducts ongoing communication and collaboration with member, family caregiver, or member's
designated representative, as well as with member's PCP and other significant health care providers
Monitors provision of services by Agency network providers to ensure they are appropriate and in
accordance with the member's care plan
Conducts ongoing monitoring of member's health, safety, and functional status, and progress towards
Provides coordination of care transitions, including discharge and transition planning from hospital or
Determines member eligibility for program and quality initiatives including diabetes management
program, falls prevention program, etc.
Facilitates establishment of Advance Care Planning and assuring appropriate administration of the
member's Health Care Proxy.
Reviews member's medical status and issues, identifying follow up issues
Serves as primary contact with member's PCP or specialist physicians as well as member's long-term
care service providers
Monitors member's medication adherence
Counsels member on his/her medical condition and provides education/coaching on self- management
or care giving by family members
Conducts monthly outreach to member to check on member's status
Updates member case records.
Participate in Quality Assurance and Improvement Activities as directed by Director of Care
NYS license and current registration as a registered nurse
Minimum of one-year experience in clinical practice, case management, care management or home
Experience in managed care and/or care management preferred
Experience with geriatric population preferred.
Preferred qualifications for a Care Manager include a bachelor s or master s degree in health, human
or education services and one year of care management experience
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