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Company Name :
Tufts Health Plan
Location : Remote
Position :

Job Description : We enjoy the important work we do every day on behalf of our members.
Please note: As of January 18, 2022, all employees — including remote employees — must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.
Job Summary
Under the administrative direction of the Clinical Manager, the Nurse Case Manager (NCM) for Senior Care Options (SCO) is responsible to manage all aspects of member care for a panel of frail elderly, while working within a healthcare team. The NCM directly interfaces with physicians, other members of the primary care team, members, and their caregivers in identifying risk factors, conducting assessments, and developing and implementing care plans to comprehensively manage their members’ care.
Job Description
The NCM will have a clear understanding of the role and will demonstrate a commitment to executing on the following responsibilities:
Ability to travel frequently to member’s homes, hospitals, skilled nursing facilities, PCP office practices and other sites where patients receive care
Timely completion of initial and ongoing geriatric assessments
Development and communication (with member, caregiver and primary care physician/primary care team) of an individualized plan of care
Completion of the Minimum Data Set-Home Care (MDS-HC)
Facilitation of member and caregiver access to community resources relevant to the member’s needs, including referrals to Adult Day Health, Adult Foster Care and the Personal Care Attendant Program.
Participation in routine primary care team meetings
Pro-active management and follow-up (via home visits and by telephone) according to the member’s care plan
Management and coordination of all transitions of care, including:
Communicating care plan to providers in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care) and ensuring providers receive timely clinical data that may impact healthcare treatment decisions
Direct caregiver support
Serves as a member advocate and facilitator to resolve issues that may be barriers to care
Provide education and coaching to the member, family, and/or caregiver about health status, treatment options, goals of care, and health insurance benefits to assist members in making the most informed decisions and help promote self-management
Work cooperatively as a team member across multiple levels within the organization
Demonstrate initiative in achieving individual, team, and organizational goals and objectives
Must be able to prioritize work and develop strategies for adapting to constantly changing priorities and urgent needs.
Regard for confidential data and adherence to corporate compliance policy
Demonstrate cultural competency and sensitivity
Demonstrate the ability to work autonomously
Requirements
EDUCATION: (Minimum education & certifications required)
Bachelors of Science in Nursing (BSN) and Registered Nurse with current, unrestricted state license is required.
EXPERIENCE: (Years of experience)
Minimum 3 years clinical nursing experience required
Experience in case management managing geriatric/chronic illness populations required
Experience within a SCO program highly preferred
Experience in Medicare and/or Medicaid managed care preferred
Proficient in computer use, the Internet, and health information technology required
Case management certification a plus
SKILL REQUIREMENTS: (Include interpersonal skills)
Work cooperatively as a team member across multiple levels within the organization
Demonstrate initiative in achieving individual, team, and organizational goals and objectives
Must be able to prioritize work and develop strategies for adapting to constantly changing priorities and urgencies.
Regard for confidential data and adherence to corporate compliance policy
Demonstrate cultural competency and sensitivity
Demonstrate the ability to work autonomously
What we build together changes our customer’s health for the better. We are looking for talented and innovative people to join our team. Come join us!
Please note: As of January 18, 2022, all employees — including remote employees — must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.

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By Richard