Centers Plan for Healthy Living

Complex Care Manager

US-NY-Staten Island
3 months ago(10/27/2017 3:13 PM)
# of Openings
Complex Care




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Centers Plan for Healthy Living (CPHL), is a Managed Care Organization servicing members with Medicare and/or Medicaid.  Our goal is to provide members and all those involved in their care with the guidance and health plan choices they need for healthy living. CPHL is committed to providing quality, coordinated health care to some of the most honored and yet still vulnerable members of our community.




The Complex Care Nurse Manager serves as the overall care navigator for CPHL’s FIDA, MAPD and D-SNP members, coordinating a continuum of care for all medical, behavioral and social service needs and is responsible for coordinating care management and the Interdisciplinary Team for assigned members. For our FIDA Participants, the Complex Care Nurse Manager is the leader of the Interdisciplinary (IDT) Team, which is responsible for the overall management and coordination of care of members enrolled in the FIDA program. The same applies for our D-SNP members, where the Complex Care Nurse Manager serves as the point person who leads the Interdisciplinary Care Team (ICT). The Interdisciplinary Team for both the FIDA and D-SNP lines of business works collaboratively and is responsible for a full array of functions, including assessment and reassessment, person-centered care plan (PCSP) development, negotiation of care plan with member, caregivers, and providers, placement of services, tracking and monitoring service placement, monitoring of clinical status, reassessment and modification of care plan based on changes in member status. The Complex Care Nurse Manager is the team leader and facilitator with overall responsibility for assuring that the IDT or ICT is involved in the member’s care, that the person-centered care plan is addressing member needs, that services are appropriate and that there is regular and ongoing engagement with member, family, assessment nurse and other care team members. Due to the population we serve, there is a strong emphasis on Disease Management, particularly involving chronic illnesses that require ongoing education and monitoring.







  • Provides case management through telephonic care management, care planning, implementation, care coordination, monitoring, and evaluation to ensure member receives services and supports required to meet medical, behavioral health, psychosocial, educational and cultural care needs
  • Develops, facilitates, and communicates a person-centered plan of care in active participation with the member, his/her significant other, primary caregiver, the primary and attending physicians, assessment nurse and various other members of the IDT/ICT involved in the member’s care.
  • Identifies member-specific barriers, issues, and interventions to assist and educate the member in meeting short and long term plan of care goals and requests authorization for services based on agreed upon member care plan
  • Ongoing monitoring of member status, review of member UASNY assessments and clinical documentation (for all but the MAPD line of business), appropriateness of person-centered care plan and services in coordination with the Interdisciplinary Team
  • Coordinates Interdisciplinary Team case conferences to review clinical assessments, develop an update person-centered care plan and determine follow up frequency with the team.
  • Leads and maintains ongoing two-way communication with members of Interdisciplinary Team: the member, assessment nurse, member, PCP, other specialists, home care and other community providers to assist in development of member-centered care plan and monitors status.
  • Acts as an advocate for members and their families, linking them to other members of the Interdisciplinary Team to help them gain knowledge of their disease processes and to identify community and other resources to improve and/or maintain maximum level of independence.
  • Recognizes quality of care issues and escalates the issues appropriately
  • Complies with all CPHL’s standards of care and documentation submission
  • Participates in on-call scheduling
  • Participates in other meetings as requested
  • Participates in quality improvement initiatives
  • Other duties as assigned



Education and Experience:



Type of Experience:


Knowledge of current community health practices for the frail adult population, behavioral health and cognitively impaired seniors and disabled including knowledge of physical health, aging and loss, chronic disease processes, appropriate support services in the community, frequently used medications and their potential negative side-effects, depression, challenging behaviors, Alzheimer’s disease and other disease related dementias, issues related to accessing and using DMEs.


Understanding of and sensitivity to members cognitive ability, means of communication, cultural differences and needs of the community are essential. Must be adept at operating within a diverse and multi-cultural work environment and community of members such as Spanish, Chinese, Russian, Creole and Korean.



Graduate of a 2- 4 year accredited nursing program;

Active and unrestricted NYS RN license

Strong written and verbal communication skills.

Proficient in the use of Microsoft office Suite tools



Bachelor of Science in Nursing or advanced degree

CCM certification

Minimum 2 years Care Management experience with the geriatric population and /or minimum of 2-4 years clinical nursing experience in home health care or MLTC

Knowledge of UAS-NY assessment





Experience working within community based home health organizations

Experience working within a managed care environment


Specific Technical Skills


Required: Microsoft Office suite 


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