Centers Plan for Healthy Living

  • Complex Care Manager

    Job Locations US-NY-Staten Island
    Posted Date 3 months ago(12/27/2018 1:48 PM)
    # of Openings
    Complex Care
  • Overview

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    The Nurse Care Manager serves as the overall care navigator for CPHL all LOB 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. The Nurse Care Manager is the leader of the Interdisciplinary  (IDT) Team, which is responsible for the overall management and coordination of care of members enrolled in CHPL programs. The Interdisciplinary team works collaboratively and is responsible for full array of functions including assessment and reassessment, person-centered care plan 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 Nurse Care Manager is the team leader and a facilitator with overall responsibility for assuring that the IDT 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.






    • 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 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, appropriateness of person-centered care plan and services in coordination with the interdisciplinary team
    • Coordinates interdisciplinary team case conferences to review clinical assessments, develop and 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, assessement nurse, member PCP, other specialists, home care and other community providers to assist in development of member centered care plan and monitor 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 process 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, 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 and 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:   Computer proficiency






    # Direct Reports:         0                     



    Physical Requirements:

    The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.



    The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification.  They should not be construed as an exhaustive list of all responsibilities, duties and skills required.














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