Job Summary

The Registered Nurse Enrollment Specialist/Care Manager is responsible for completing a comprehensive assessment to determine the correct services and benefits based on medical necessity for an enrollee. Provides plan education, transition of enrollees to the clinical services department and completes enrollment processes based on Department of Health guidelines. Care management providing advocacy, coordination and oversight of all healthcare services for an enrollee striving to deliver the best care at the right time and in the most-cost effective while meeting quality outcome standards for the enrollee case load assigned. Complies with all state and federal regulations including Health Insurance Portability and Accountability Act (HIPAA).

Core Job Responsibilities

• Identifies and coordinates enrollee services as provided by the plan and services that are not a benefit of the plan.
• Completes comprehensive assessment using the DOH approved tool to determine eligibility of enrollment.
• Educates and completes with enrollee all necessary consents and documentation.
• Completes reports as requested by Executive Director or designee.
• Initiates and carries out continuous assessment of physical, emotional, social, cultural, economic, and environmental needs of the patient.
• Observes the patient for changes in condition and follows up with appropriate services or providers to attempt to prevent disease exacerbations.
• Develops, monitors and revises a Plan of Care with the enrollee or enrollee designee that has problem, goals and interventions.
• Promotes good health practices helping the enrollee in accepting and assuming responsibility for attaining the highest level of independent functioning possible.
• Implements orders for DME items and treatments as prescribed by the physician, submitting and maintaining appropriate medical orders and documentation.
• Completes documentation per company standards/policy utilizing an Electronic Medical Record (EMR) system.
• Participates in Marketing Activities as requested by Executive Director or Designee.
• Participates in departmental and organizational committees,meetings and activities as applicable.
• Participates in the orientation of new personnel, mentors peers, and promotes collaborative teamwork.
• Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with the basic principles of professional nursing.
• Maintains a working knowledge of, and adheres to applicable federal/state regulations including, but not limited to, patient confidentiality, release of information, and Health Insurance Portability and Accountability Act (HIPAA).
• Interacts in a manner, which is professional, respectful, positive, helpful, and which promotes trust.
• Attends agency in-services and educational programs, and maintains professional growth and development.
• Participates in the quality improvement and utilization review activities to include Clinical Outcomes, Financial Outcomes, Operational Outcomes and Behavioral Outcomes of the organization.
• Excellent written, verbal and listening communication skills.
• Routinely communicates changes/updates to staff, other departments, and Supervisor as necessary.
• Utilizes varied communication styles to communicate to produce results.
• Able to work with various electronic systems and software.
• Ability to manage conflict, stress, and multiple simultaneous work demands in an effective, professional manner.
• Ability and willingness to self-motivate, prioritize, and be willing to change processes to improve effectiveness efficiency. Adapts to changing enrollee or organizational priorities.
• Ability to make independent decisions in accordance with established policies and procedures.

Education/Experience Requirements

• Bachelor of Science in Nursing
• Minimum of 3 years in community based care or health care area that cares for the community population.

Licensure/Certification Requirements

• Licensed Registered Professional Nurse
• Valid New York State driver’s license.
• Current Basic Life Support (BLS) Certification.
  

Job Details

Req Id 73722
Department SNH CLINICAL SERVICES
Shift Days
Shift Hours Worked 7.50
FTE 1
Work Schedule SALARIED GENERAL
Employee Status A1 - Full-Time
Union V01 - VNA-NYSUT NURSES UNION

EOE AA M/F/Vet/Disability

Qualified applicants will receive consideration for employment without regard to their age, race, religion, national origin, ethnicity, age, gender (including pregnancy, childbirth, et al), sexual orientation, gender identity or expression, protected veteran status, or disability.

Successful candidates might be required to undergo a background verification with an external vendor.