Nurse Case Manager II - Transition OD Care RN
: Job Details :

Apply critical thinking and evidence-based clinical criteria to support contractual rebalancing goals. Complete at least 10 NF member assessments weekly. Support the Health Plan Rebalancing Initiative goal of successful transitions. Assess, identify, screen, and transition NH members into the community. Follow up on CM referrals and visit current NH members in-person at least twice a week. Complete telephonic or in-person contact to assess the home prior to discharge. Conduct an in-person Significant Change Visit with member and Rep within 5 days of transition. Coordinate provision of services, establish Plan of Care, and document all actions taken. Contact facility's Business Office weekly to follow-up on members' census. Work collaboratively with case managers to implement interventions for high-risk community members. Drive enhanced value of health care to increase member satisfaction and retention. Engage in at least two community relations events per year. Critical Information Can...Case Manager, RN, Manager, Nurse, Healthcare, Staffing