Care Management Sr Nurse
· Manage a case load of Chronic Condition Special Needs Plans (C-SNP) and Dual Eligible Special Needs Plans (D-SNPs), providing intense care, interventions and supervision to MOC population, family members, care givers and community.
· Evaluates the condition of the member to identify the individual needs of each patient such as:
o If it is high risk (complex),
o If they are fragile, incapacitated, with chronic conditions, catastrophic or institutionalized,
o If they meet the criteria to be admitted to the various Clinical Programs.
· Establishes an individualized care plan (ICP) for each patient registered in the complex chronic conditions and high care management program using their clinical judgment and the guidelines adopted by the company. Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
· Proactively identifies problems and barriers that may affect the member by setting achievable goals and short-term or long-term management strategies.
· Performs telephone, email, fax and/or face to face interactions to determine needs for continued care.
· Attends and facilitates educational campaigns to impact members health, gaps in care and utilization. Develop and present health education activities, promotion of the disease management, patient training workshops, conferences and community presentations.
· Communicate patient benefits and responsibilities timely and accurately.
· Maintains effective communication about the condition and treatment of the member with the primary care physician (PCP), the service provider and with the same patient, to evaluate their progress, ensure integration into physical and mental health care, promote self-care and clarify any situation related to the clinical services it receives.
· Develops and implements transition of care for patients in conjunction with hospital-based care managers.Inter
faces with Medical Directors and physician advisors on the development of care management treatment plans.
· Assess the effectiveness of the treatment of members whenever necessary and participate in case discussions with the Primary Care Physician (PCP) and/or any other provider related to the patient whenever it is necessary to re-evaluate the ICP and coordination of the necessary services.
· Bachelor’s Degree (BD) in Nursing with at least five (5) years of experience, preferable in specialized treatment centers, emergency room and / or dialysis center.
Understanding and/or direct experience of Model of Care (MOC) elements.
· Current/ valid license in Puerto Rico Register Nurse, in Good Standing or without restrictions.
Member of College of Nursing Professional of Puerto Rico.