Nurse Care Manager (BPS)

Reports to: CARE MANAGER SUPERVISOR, HEALTH SERVICES 

Location:    Bronx, New York 10453

Hours: 35 hours, Exempt

Major Duties:

• Obtains required Care Management enrollment consents from the individual or legal guardian


• Completes initial and ongoing needs assessments (Child and Adolescent Needs and Strengths; CANS) to determine the individual’s most appropriate level of care management.  


• Responsible for the overall management of the patient’s Individualized Plan of Care.  Through the creation of an Individual Plan of Care the Care Manager is able to:


• Coordinate the enrollee’s provision of services including as per their acuity level. 


• Support adherence to treatment recommendations


• Monitor and evaluate a patient’s needs, including prevention, wellness, medical, mental health, care transitions, and social and community services where appropriate.  


• Meets client contact requirements (keeping in mind that caseloads may be “blended”):


• Care Managers serving children will be required to have some face-face visits on a consistent schedule as per the mandates of their acuity level (high, medium, or low). 


• Meets Care Management documentation requirements in a timely and accurate manner by effectively utilizing designated Care Management Portal (Medicaid Analytics Performance Portal; MAPP) and Electronic Health Records (EHRs) as needed


• Functions as an advocate for clients within the agency and external service providers


• Promotes wellness and prevention by linking enrollees with resources and services based on their individual needs and preferences


• Educate the child/caregiver on care of chronic conditions, immunization, screening and other preventive interventions.  


• Helps clients to obtain and maintain public benefits necessary to gain health care services, including Medicaid and cash assistance eligibility, Social Security, SNAP, housing, legal services, employment and training supports, and others. 


• Effectively communicates and shares information with the individual and their families and other caregivers with appropriate consideration for language, literacy and cultural preferences.


• Conducts care planning meetings/conferences and serves as an interdisciplinary team member to effectively provide/coordinate comprehensive and holistic care


• Identifies available community-based resources and actively manages appropriate referrals, access, engagement, follow-up and coordination of services


• In the event of hospital admissions, actively engages in the discharge planning process ensuring that the patient has all recommended post discharge services in place prior to discharge


• Attends and participates in ongoing staff development trainings to enhance skills needed to effectively meet the demands of the Care Manager position


• Ensure that child has periodic evaluations and follow up treatment for dental, vision and hearing care, following Medicaid EPSDT guidelines


• All other duties, as needed

Qualifications:

• Registered Nurse or LPN with two years’ experience


• Bilingual is a plus 

The candidate must possess the following Experience:

• Relevant expertise and experience in serving children and families in child welfare, developmental disabilities, mental health, healthcare and/or other systems as well as those receiving preventive services.


• Care Managers serving high acuity enrollees will be required to have demonstrated knowledge and understanding of the needs of such children and their families as evidenced by additional years of experience, education, or training.


• Care Managers assigned to children who have medical fragility must have extensive experience in coordinating their care


• Experience providing service coordination and information, linkages, and referrals for community-based services.  

In addition the candidate must demonstrate the following Competencies:

• Excellent writing, communication, and organizational skills


• A passion for serving children and families with special needs


• Ability to travel to community-based agency offices, participant’s communities, and homes within assigned catchment area 


• Ability to receive feedback to professionally grow and/or improve


• Proven self-management abilities, including meeting deadlines, ensuring compliance with agency policy and procedures, and overseeing complete and timely maintenance of agency records, in accordance with contractual requirements.

General Requirements: All staff are expected to be committed to the mission, vision, and values of Good Shepherd Services, which includes involvement in quality improvement activities and a willingness and ability to work within a culturally diverse environment.