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Job Description
Job Title Field Based RN Care Manager (Sheila Vosburg EDOS 3/4/13)
Job ID 664030
Begin Date 1/22/13
Duration
Location Buffalo,  NY
Other Location
Description At APS Healthcare, we are passionate about changing behaviors of all constituents in the healthcare system to improve health, optimize clinical quality, and reduce associated costs. Our mission is quite simply to improve the health of those we serve.

APS is managing the Northeast Population Health Management (NPHM) Program, which provides utilization management services and supports high and moderate-risk clients with chronic illness through field disease management and medical care coordination. This program supports providers and assists clients in becoming and staying healthy by coordinating treatment coverage, reinforcing treatment plans and by educating patients on making responsible decisions about their healthcare.

APS is seeking a Field-Based RN Care Manager to join this new and exciting program. The RN will provide on-site outreach, disease and/or case management, education and support to plan members to support healthy lifestyle choices & to reduce long term effects of chronic illnesses. The Care Manager will perform clinically based activities to coordinate care between the members, providers and community based health organizations. This position will be based remotely from a home office and requires travel within the Rochester region.

Essential Functions:
• FINANCIAL: Assists Supervisor and Manager in ensuring achievement of contractual financial obligations, including service delivery in a cost effective and efficient manner and through support of budgetary adherence by reporting accurate and timely work hours and expenses incurred during course of position duties.

• OPERATIONAL: Ensures the responsible and professional delivery of comprehensive service and care delivery of the care management program with a focus on inappropriate acute care utilization within high and moderate risk member population, specifically complex chronic condition cases. Evaluates coordination with medical home and community resources. For high or moderate acuity members discharged to home, executes on transition of care activities, including visits to member within 3 business days of discharge to conduct assessment and carries out specific transition of care/post-discharge interventions weekly for 45 days post-discharge. Conducts assessments, develops action plans and associated interventions and sets goals for behavior modification within the scope of practice for high and moderate risk enrollees. Collaborates with providers to ensure closure of identified gaps in care for high and moderate risk enrollees.

• CORPORATE CULTURE: Promotes mission, vision and values of program. Demonstrates ownership of position and proactively carries out position duties with limited direction and/or oversight. Maintains professional licensure(s), certification(s), and completes required continuing education credits to support ongoing position requirements. Promotes and facilitates positive team atmosphere by demonstrating the ability to work within a team and support team efforts, as well as sharing knowledge with peers and other team members.

• QUALITY/SATISFACTION: Proactively engages in delivery of quality management program activities that are the direct responsibility of the Care Management team. Assists in the achievement and ongoing maintenance of federal/state regulatory and accreditation requirements for defined programs. Demonstrates and facilitates customer service excellence. Meets benchmark performance metrics for monitoring activities. Communicates pertinent information and/or potential quality issues identified during daily activities to supervisor in accordance with corporate and departmental policies.

Education:
• Associates Degree in Nursing required; BSN/MSN preferred.
• Current, unrestricted RN licensure in NY is required.

Qualifications:
• Minimum 3 years hands-on nursing experience required. Work in clinical setting serving medically or socially complex patients preferred.
• Previous experience in care management, disease management and/or case management preferred. Behavioral/mental health experience helpful.
• Public health nursing or home health background preferred.
• Knowledge of medically complex/fragile, elderly patients with complex socioeconomic issues.
• Knowledge of adult learning and behavior change principles preferred.
• An understanding of community, social resources, i.e. transportation, housing and food.
• Knowledge of cultural preferences of community in which Care Manager operates.
• Strong clinical and social assessment skills, consistent with state licensure scope of practice requirements.
• Ability to assess home environment for safety issues, including fall risk.
• Ability to create successful, professional partnerships with Providers and staff.
• Excellent verbal communication skills, electronic clinical management system documentation skills.
• Proficient in Microsoft Office and Internet/Web Navigation.
• Strong prioritization and organizational skills.
• Ability to adapt cultural practices/sensitivities to the application of interventions.
• Ability to assess member health status, social needs, cultural beliefs, consistent with state licensure scope of practice requirements.
• Must be able to prioritize and target interventions, consistent with state licensure scope of practice requirements designed to support long term behavioral change.
Required Skills Education:
• Associates Degree in Nursing required; BSN/MSN preferred.
• Current, unrestricted RN licensure in NY is required.

Qualifications:
• Minimum 3 years hands-on nursing experience required. Work in clinical setting serving medically or socially complex patients preferred.
• Previous experience in care management, disease management and/or case management preferred. Behavioral/mental health experience helpful.
• Public health nursing or home health background preferred.
• Knowledge of medically complex/fragile, elderly patients with complex socioeconomic issues.
• Knowledge of adult learning and behavior change principles preferred.
• An understanding of community, social resources, i.e. transportation, housing and food.
• Knowledge of cultural preferences of community in which Care Manager operates.
• Strong clinical and social assessment skills, consistent with state licensure scope of practice requirements.
 
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