RN Care Manager (DSNP)

The Registered Nurse (RN) Care Manager for Belong Health's DSNP program is responsible for providing comprehensive, member-centered care management services for Medicare beneficiaries with complex medical, behavioral health, and social needs. This role applies care management principles to assess member needs, develop and implement individualized care plans, coordinate services across the continuum of care, and maintain collaborative relationships with provider practices, community-based organizations, caregivers, and the Belong Health team.

• →Responsible for providing clinical oversight to medically complex Medicare beneficiaries
• →Orient new members to the Belong Health DSNP program and educate the member and/or caregivers on care management services.
• →Advocate, empower, inform, and educate beneficiaries on self-management techniques.
• →Conduct assessments to identify barriers and opportunities for intervention.
• →Complete health risk assessments, reassessments, and other clinical evaluations in accordance with program requirements.
• →Identify members requiring intensive care management interventions and coordinate appropriate clinical, behavioral health and community-based services.
• →Develop and implement an individual care plan (ICP).
• →Monitor member progress toward care plan goals and revise interventions based on changing clinical or social needs.
• →Lead interdisciplinary care team meetings.
• →Collaborate with provider, social workers, discharge planners, and community-based service providers to coordinate care and achieve care plan goals.
• →Support transitions of care activities including post-discharge outreach, medication reconciliation support and coordination with providers and caregivers.
• →Document all care management activities in the appropriate system in accordance with internal and established documentation procedures.
• →Work directly with members, their families and/or advocates, providers, and community service organizations on an ongoing basis to coordinate care and reduce barriers to care.
• →Utilize population health, risk stratification and care management technology platforms to prioritize outreach and interventions.
• →Promote a culture of accountability and performance to both meet and exceed personal service vision goals and ensure timely and satisfactory resolution of highly complex, specialized, and non-routine customer issues.
• →Other duties as assigned.

This role does not have supervisory responsibilities.

• Working knowledge of Medicare and Medicaid programs and experience with regulatory requirements and reporting.
• Proficient in navigating multiple systems; demonstrated PC skills using Microsoft applications.
• Two (2) or more years’ experience in a health plan, health care organization, Community Based Organization, or social services environment.
• Experience supporting Medicare, Medicare Advantage, Medicaid, Dual Eligible Special Needs Plans (DNP), or other complex populations.
• Experience delivering care management services in a telephonic and/or virtual environment.
• Understanding of needs and dynamics of elder care services, disadvantaged, disengaged populations.
• Knowledge of care coordination, transitions of care, motivational interviewing, and person-centered care planning principles.
• Experience participating in cross departmental projects and policy and procedure changes, including coordination of activities and initiatives across departments.
• Excellent customer service, active listening, issue assessment, trend identification, and analytical skills, with a demonstrated ability to problem solve effectively and efficiently.
• Commitment to high ethical standards in all work; protects the privacy of member and company data and exercises discretion in handling confidential member information.
• Excellent oral and written communication skills, including presentation skills.
• Strong organizational and follow-through skills.
• Demonstrated ability to manage a caseload of medically and socially complex members.
• Ability to work independently and effectively within a fully remote and highly collaborative team environment. 

• Demonstrated experience in a managed care, Medicare Advantage, DSNP, or value-based care environment.
• Knowledge of community services and resources supporting older adults, individuals with disabilities, and underserved populations
• Care Management Certification preferred (CCM, ACM, CMGT-BC, or equivalent).
• Bi-lingual Spanish speaking preferred 

• Graduate of an accredited nursing program required.
• Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) required.
• Bachelor of Science in Nursing (BSN) preferred. Equivalent education and experience may be considered. 

• An active, unrestricted nursing license in the state of NY (RN).
• Ability to obtain and maintain licensure in additional states if required by business needs.
• Care Management Certification preferred.

The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually quiet. Most of the work is performed on a computer and in a sedentary environment. 

This role may require some travel based on business needs, including but not limited to traveling to semi-annual onsite meet ups.

• $80,000-$95,000