Community Based Care Manager - RN or SW - Nevada - R9650-3

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Job Summary

The Community Based Care Manager collaborates with members of an inter-disciplinary care team (ICT), providers, community and faith-based organizations to improve quality and meet the needs of the individual, natural supports and the population through culturally competent delivery of care and coordination of services and supports. Facilitates communication, coordinates care and service of the member through assessments, identification and planning, and assists the member in creation and evaluation of person-centered care plans to prioritize and address what matters most, behavioral, physical and social determinants of health needs with the aim to improve the of lives our members.

Job Summary

The Community Based Care Manager collaborates with members of an inter-disciplinary care team (ICT), providers, community and faith-based organizations to improve quality and meet the needs of the individual, natural supports and the population through culturally competent delivery of care and coordination of services and supports. Facilitates communication, coordinates care and service of the member through assessments, identification and planning, and assists the member in creation and evaluation of person-centered care plans to prioritize and address what matters most, behavioral, physical and social determinants of health needs with the aim to improve the of lives our members.

Essential Functions

• Engage the member and their natural support system through strength-based assessments and a trauma-informed care approach using motivation interviewing to complete health and psychosocial assessments through a health equity lens unique to the needs of each member that identify the cultural, linguistic, social and environmental factors/determinants that shape health and improve health disparities and access to public and community health frameworks
• Facilitate regularly scheduled inter-disciplinary care team (ICT) meetings to meet the needs of the member
• Engage with the member in a variety of settings to establish an effective, professional relationship. Settings for engagement include but are not limited to hospital, provider office, community agency, member’s home, telephonic or electronic communication
• Develop and regularly update a person-centered individualized care plan (ICP) in collaboration with the ICT, based on member’s desires, needs and preferences
• Identify and manage barriers to achievement of care plan goals
• Identify and implement effective interventions based on clinical standards and best practices
• Assist with empowering the member to manage and improve their health, wellness, safety, adaptation, and self-care through effective care coordination and case management
• Facilitate coordination, communication and collaboration with the member the ICT in order to achieve goals and maximize positive member outcomes
• Educate the member/ natural supports about treatment options, community resources, insurance benefits, etc. so that timely and informed decisions can be made
• Employ ongoing assessment and documentation to evaluate the member’s response to and progress on the ICP
• Evaluate member satisfaction through open communication and monitoring of concerns or issues
• Monitors and promotes effective utilization of healthcare resources through clinical variance and benefits management
• Verify eligibility, previous enrollment history, demographics and current health status of each member
• Completes psychosocial and behavioral assessments by gathering information from the member, family, provider and other stakeholders
• Oversee (point of contact) timely psychosocial and behavioral assessments and the care planning and execution of meeting member needs
• Participate in meetings with providers to inform…