Provides telephonic assessments of members’ medical, psychosocial, physical, and spiritual needs. Utilizes completed UAS-NY assessments to develop a Person-Centered Service Plan (PCSP).

Responds to changes in members’ condition/sentinel events (i.e. level of care changes, changes in family support, changes in housing, etc.) by revising the PCSP and communicating changes with interdisciplinary care team and PCP.

Responds to requests for service within Medicare/Medicaid regulated time frames utilizing appropriate correspondence as per DOH/CMS regulations and departmental workflows.

Participates in and presents cases at the Interdisciplinary Care Team meetings to discuss any changes in member’s condition/sentinel events (i.e. level of care changes, changes in family support, changes in housing, etc.) identified during assessment process.

Collaborates with interdisciplinary care team members, such as Primary Care Physician, Social Worker, Specialists, Hospice/Palliative team, and Chief Medical Director when complex social/medical focus areas are identified during the assessment/care planning process as per unit workflows.

Educates members on Advanced Directives/Health Care Proxy/Power Of Attorney (POA) and helps to facilitate the completion of such documentation.

• Associate’s Degree in Nursing for experienced candidates
• BSN for new graduates
• NYS RN license required
• CCM preferred
• 1 year of RN experience in managed care, home care, acute care or nursing home preferred