- Provide proactive primary and acute care to members.
- Manage members with acute change in condition in collaboration with primary care physician and the ICT.
- Reviews and manages pharmacotherapy of each member, collaborating with clinical pharmacist and physicians when necessary.
- Prescribe appropriate medications, including controlled substances in accordance with NYS law.
- Identify, treat, and document changes in condition.
- Order, review and/or follow-up with treatments and diagnostic testing.
- Daily review nursing home reports, logs, medical records, etc.
- Complete timely health risk assessments.
- Complete routine monthly comprehensive assessments.
- Ensures appropriate and timely utilization of services requests, such as consultation with specialists.
- Ensures a smooth transition and assists in the coordination of care across various health care settings.
- Attends nursing home meetings, participate in ICT meetings involving CPHL members.
- Communicate with the nursing home staff on a regular and as needed to discuss changes in condition and/or the care plan.
- Communicate with ICT.
- Communicate with the family or designated representative regularly about significant changes in condition and/or therapies.
- Discuss and educate member and designated representative on ACP.
- Act as point of contact for member, family or designated representative, throughout transition process, change in condition, routine updates.
- Works with the ICT to optimize the health and functional status of the members. Also works to enhance pain management strategies, thereby improving the quality of life of the members.
- Provide clinical education and support to nursing staff as needed.
- Provide ongoing education and support to member and family or designated representative regarding the member’s health status, established goals.
- Participate in pre-planned marketing events with nursing home residents and families.
- Active role in training nursing home staff to CPHL MOC.
- Participate in an ‘on call’ program, providing telephonic and/or on site assessments and interventions for the members after hours and on weekends.
- Management of the skilled day process.
- Comply with nursing home and CPHL policies and procedures.
- Follow both nursing home and CPHL reporting procedures for incidents, appeals, grievances.
Strong communication skills
Working knowledge of clinical documentation requirements & Medicare Risk Adjustment coding
This position has no supervisory responsibilities.
This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, and photocopiers.
This is largely a sedentary role; however, some filing is required. This would require the ability to lift files, open filing cabinets and bend or stand as necessary.
Position Type and Expected Hours of Work
This is a full-time position. Days and hours of work are Monday through Friday, 9 a.m. to 5 p.m.