Provides clinical care coordination services to support PHPs’ model of care as well as CMS’s and NYSDOH’s contractual managed care agreements. This qualified professional is the point person responsible for leading a care coordination team and overseeing all care coordination and care management supports and services to assigned participants. Responsibilities include, but are not limited to, assisting the member in developing, implementing, and monitoring person-centered service plans (Life Plans) using participant health risk assessments and other clinical, social, and functional information to meet members’ needs and preferences. Also, responsible for serving as the lead of the participant’s Interdisciplinary Team (IDT).
Duties and Responsibilities:
- Provide supervision to assigned Care Coordinators (QIDP’s) as well as oversee all care management duties of assigned participants;
- Conduct participant assessments and develop person-centered Life Plans in collaboration with participants’ IDTs;
- Implement, update, and monitor Life Plans and facilitate individualized Life Plan reviews and approval processes;
- Ensure integration of all needed and preferred supports and services (i.e. medical, behavioral, social, habilitation, dental, psychosocial, and community-based and facility-based long-term supports and services, etc.);
- Lead IDTs and assist in coordinating IDT and Life Plan meetings for participants;
- Communicate with IDTs, physicians, and other providers at regular intervals to monitor and update Life Plan(s);
- Provide education to participants, caregivers, circles of support, IDTs, and other stakeholders;
- Maintain participant Life Plan and health risk assessment information in secure system;
- Conduct in-person visits to participants’ residences as needed;
- Provide on-call after-hours clinical coverage on a rotating basis,
- Flexibility in work schedule is required, with some evening and, or weekend hours as needed,
- Promote PHPs’ mission and values;
- Utilize a person-centered approach and support participants to be as independent as possible,
- All other duties as assigned.
- Current license and, or applicable registration as a Registered Nurse, Social Worker or Psychologist to practice in the State of New York required;
- Associate’s Degree in a healthcare related field required, with a Bachelor’s Degree preferred;
- Minimum of 1+ years’ work experience working with people with intellectual and, or developmental disabilities;
- Knowledge of: Physical health, aging and loss, appropriate community support services, frequently used medications and their potential negative side-effects, depression, challenging behaviors, Alzheimer’s disease and other disease-related dementias, behavioral health, and issues related to accessing and using durable medical equipment, as appropriate also required;
- Strong communication skills including verbal and written communication skills, along with strong interpersonal and organizational skills also required;
- Proficiency with health-related computer applications;
- Valid Driver’s License to travel within NYS preferred, and
- Must be able to travel and adhere to PHP’s travel policies.
Requirements of All Positions:
- All employees shall meet PHP’s Compliance and Privacy Regulations, and attend at a minimum of one (1) hour of Compliance and Privacy educational training annually;
- All employees shall master PHP’s Model of Care and complete all training requirements within the first thirty (30) days of employment and annually thereafter, or as required by state and federal regulations;
- All employees are required to maintain confidentiality, protect privacy, comply with Protected Health Information regulations, and report violations;
- Perform functions as they relate to “Improving Health Care Quality” as defined in the National Association of Insurance Commissioners Supplemental Health Care Exhibit that:
1. Improve health outcomes;
2. Prevent hospital readmission;
3. Improve patient safety and reduce medical errors, and
4. Provide wellness and health promotion activities.
Physical Demands and Work Environment:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel utilize objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, kneel, crouch or crawl.
The employee must occasionally lift and/or move up to 25 pounds, and infrequently up to 50 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus. The noise level in the work environment is usually moderate.
Equal Opportunity Employer