Nurse Case Manager (NaviCare) Central MA
Location: Worcester Massachusetts
Description: Fallon Community Health Plan is currently interviewing Nurse Case Manager (NaviCare) Central MA right now, this vacancy will be placed in Massachusetts. For complete informations about this vacancy opportunity kindly see the descriptions. About Fallon Community Health Plan:
Founded in 1977, Fallon Community Health Plan is a nationally recognized, not-for-profit! health care services organization. From traditional health insurance products available throughout Massachusetts for all populations, to innovative health care programs and services for independent seniors, FCHP supports the diverse and changing needs of all those it serves. FCHP has consistently ranked among the nation’s top health plans, and is the only health plan in Massachusetts to have been awarded “Excellent†Accreditation by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fchp.org.
About NaviCare:
NaviCare HMO is a Medicare Advantage Plan and Senior Care Options program from Fallon Community Health Plan. Medicare Advantage contracts between the federal government and managed care organizations. NaviCare HMO combines all the benefits that are covered by Medicare and MassHealth Standard into one program. Navicare HMO also includes Medicare Part D.
Pos! ition Overview:
The NaviCare Nurse Case Manager (NCM) ! assesses an Enrollee’s clinical/functional status and develops a plan to coordinate a continuum of care consistent with the Enrollee’s health care needs and/or goals. The care plan supports the Enrollee attaining and/or maintaining an optimal functional status.
The NCM is an active participant in the Enrollee’s Primary Care Team (PCT) and is an advocate for the Enrollee.
The NCM is actively involved with the Enrollee at times of care transition, including but not limited to planned and unplanned admissions, and works in conjunction with the Enrollee’s Navigator to ensure care plan communication between all providers and members of the PCT.
The NCM coordinates care between multiple medical and Primary Care Team Providers. The NCM is able to identify services, care delivery settings, and recommends alternatives where appropriate.
The NCM monitors the care and provides consistent feedback to team on progress. The NCM collaborates and! works with all members of the Primary Care Team and, when appropriate, FCHP Inpatient Nurse Care Specialists to ensure an effective care plan to meet Enrollee care needs. The NCM may attend Facility Discharge Planning Rounds and works to ensure a smooth discharge and transition.
The NCM’s assessment and completion of the Minimum Data Set Home Care (MDS HC) forms for enrollees residing in the community setting determines the level of monthly FCHP reimbursement for the individual enrollee from the Massachusetts Executive Office of Health and Human Services.
The NCM oversight of the Minimum Data Set 3.0 form for all enrollees residing in the long-term care setting determines the level of monthly FCHP reimbursement for the individual enrollee from the Massachusetts Executive Office of Health and Human Services.
The NCM assesses the need for, and determines the number of Personal Care Attendant (PCA) Program hours an Enrollee will receive weekly if ! Program criteria is met. (NaviCare pays for the PCA Program).
! The NCM is an advocate for Enrollees, and works to ensure the Enrollees participate in the development and approval of their care plans as appropriate.
The NCM facilitates prompt and easy access to care appropriate to the disease or condition in line with applicable and appropriate clinical guidelines.
The NCM utilizes varied interviewing techniques including but not limited to motivational interviewing, and employs culturally sensitive strategies to engage and work with Enrollees. The NCM goes to the Enrollee in the home and long-term care setting to assess needs and monitor progress to goals.
Responsibilities
Reviews Enrollee enrollment data, claims data, urgent and emergency room utilization, acute/skilled nursing inpatient census, referrals from Primary Care Team (PCT) and vendors, and other appropriate data prior to initiating any Enrollee contact
Contacts Enrollees/caregivers telephonically and/or in person to at time of enrollment, ! at time of care transition, and/or ongoing based upon Program requirements to:
1. Perform a nursing needs assessment
2. Assess the health needs of the Enrollees and/or
3. Recommend modifications to care plan elements
Completes a home visit for all community dwelling assigned Enrollees prior to or in the first month of enrollment, any time there is a clinical change, or at intervals defined by EOHHS in order to complete the Minimum Data Set Home Care (MDS HC) form and submits to EOHHS via the Virtual Gateway to obtain a rating category which determines FCHP EOHHS monthly reimbursement
Completes a facility visit for all long term care dwelling assigned Enrollees prior to or in the first month of enrollment, any time there is a clinical change, or at intervals defined by EOHHS in order to obtain and validate the Minimum Data Set 3.0 form completed by the long term care facility which determines the FCHP EOHHS monthly reimbursement. The NCM ensures the Navig! ator sends the MDS 3.0 forms to EOHHS per Department process
Manage! s the Enrollee panel to ensure there are not lapses in the EOHHS rating category approvals (lapses may result in reductions in State funding)
Responsible for updating and maintaining accuracy of panel access data base lists â€" processes according to Department guidelines
Performs Enrollee assessments for supportive programs paid for the Program including but not limited to the Personal Care Attendant (PCA) Program. The NCM’s assessment of the Enrollee’s need for hands on PCA services determines the number of hours of PCA the Program will pay for on a weekly basis
Is a member of the Enrollee’s PCT and attends all meetings even if not actively involved with the Enrollee providing suggestions and feedback as appropriate
Works closely with the Enrollee’s Navigator to initiate PCT meetings with PCT members/enrollees/caregivers as necessary and ensures the Navigator coordinates the participation of appropriate interdisciplinary team members
As a membe! r of the PCT, updates all relevant team members regarding the Enrollee’s status and develops/proposes changes to the care plan (PCT approves changes)
Documents in the FCHP UM Staff Inpatient Case whenever an Enrollee has an inpatient event to ensure the FCHP UM Staff know the Enrollee situation and discharge planning needs
Works with members of the PCT/FCHP UM staff, assisting with difficult or complex care delivery or discharge planning needs
Attends facility discharge planning rounds, advocating for Enrollee care needs and facilitation of care plans that meet care needs
Works with PCT members to coordinate a continuum of care for Enrollees consistent with the Enrollee’s health care goals and needs
Identifies, aligns, and utilizes health plan and community resources that impact high-risk/high cost care
Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the Enrollee attain! s pre-determined outcomes
Resolves conflicts among participants in ! the care planning process
Streamlines the focus of the Enrollee’s healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care
Works collaboratively and cohesively with all members of the Primary Care Team (including the Primary Care Physician, Geriatric Social Service Coordinators from the Aging Service Access Points, Long Term Care Facility Liaisons, Enrollees/caregiver and others including but not limited to the Program Behavioral Health Clinician) as appropriate
Reviews Enrollees with the Program Geriatrician and advocates for Administrative Exception considerations as appropriate
Coordinates and approves services provided by skilled home health care agencies and in home/facility providers to coordinate plans for Enrollees served in the Program
Maintains an ongoing awareness of clinical, social, and financial resources available in the communi! ty/long term care setting as well as State/Federal and national resources
Maintains documentation of individual care management plans, interventions, cost/benefit analyses, and other statistics as needed, to demonstrate the clinical quality outcomes and cost-effective financial impact of care management
Uses the appropriate FCHP IT application(s) including the Centralized Enrollee Record to document all case activity and facilitate appropriate communication between the PCT Team
Uses the FCHP Core System to view eligibility and status of authorizations
Utilizes a successful communication style and methods to engage Enrollee’s in care management â€" does not ‘easily give up’ and works to engage Enrollee’s as appropriate
Identifies and shares best practices and innovative care management strategies with the team
Supports department colleagues, covering and assuming changes in assignment as assigned by Supervisor/Designee
Strictly observes HI! PPA regulations and the FCHP policies regarding confidentiality of memb! er information
Performs other responsibilities as assigned by the Supervisor/designee
Qualifications
Education : Graduate from an accredited school of nursing mandatory and a Bachelor's (or advanced) degree in nursing or a health care related field preferred.
License : Active, unrestricted license as a Registered Nurse in Massachusetts; current Driver’s license
Certification : Certification in Case Management strongly desired
Experience : A minimum of three to five years clinical experience as a Registered Nurse managing chronically ill/geriatric patients.
Experience working in a healthcare setting as a member of a professional clinical team required.
Experience with care coordination.
Experience in home health care, working with Enrollees who are in a long term care setting and familiarity with the MDS process a plus.
One year experience as a case manager in a managed care settin! g a plus.
Apply for this job
Your application choices are:
- .
If you were eligible to this vacancy, please email us your resume, with salary requirements and a resume to Fallon Community Health Plan.
If you interested on this vacancy just click on the Apply button, you will be redirected to the official website
This vacancy starts available on: Wed, 14 Aug 2013 15:12:59 GMT