Hospital to Home Case Manager

About the position

The Hospital to Home Case Manager (RN) is responsible and accountable for coordinating the care of CDPHP members who meet criteria for services across the continuum of care. Activities focus on the successful transition of care for CDPHP members who have been hospitalized and are being discharged, with a focus on readmission avoidance. Specific activities include member outreach, medication review, identifying barriers to care, care planning and collaboration with providers. Case Managers will also provide education and support to members who have ongoing chronic health needs, they will also serve as a resource to answer day-to-day clinical questions from members and other CDPHP business areas. The Hospital to Home Case Manager will navigate a variety of applications and platforms in the daily administration of work. They must combine strong clinical knowledge and critical thinking to coordinate and support a care plan that will monitor quality medical care for the member population serviced by CDPHP. The Hospital to Home Case Manager role is may be in a hospital facility or at CDPHP headquarters depending on program needs. They may be required to periodically meet with members in their home, physician office or community setting.

Responsibilities
? Coordinate care for CDPHP members across the continuum of care.
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? Focus on successful transition of care for hospitalized members.
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? Conduct member outreach and medication review.
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? Identify barriers to care and develop care plans.
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? Collaborate with providers to ensure quality care.
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? Provide education and support to members with chronic health needs.
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? Serve as a resource for clinical questions from members and other business areas.
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? Navigate various applications and platforms for daily work administration.

Requirements
? Registered Nurse with a current New York State license.
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? Minimum three (3) years clinical experience.
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? Experience with chronic condition management required.
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? Experience with diabetes and heart disease preferred.
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? Demonstrated ability to provide case management for complicated members.
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? Demonstrated ability to work collaboratively on a team.
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? Excellent verbal and written communication skills.
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? Valid driver's license and driving record showing no restrictions.

Nice-to-haves
? Bachelor's degree in Nursing preferred.
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? Certified Case Manager (CCM) certification preferred.
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? PRI (Patient Review Instrument) certification preferred.
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? Case management experience preferred.
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? Experience working with health, social service and funding resources preferred.
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? Experience in home care, medical office setting, hospital or managed health plan preferred.
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? Spanish speaking preferred.

Benefits
? Award-winning health care coverage.
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? Health care dollars.
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? Generous paid time off allowance.
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? Employee assistance programs.
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? Flexible work environment.
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? Incentive payment based on performance.
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? Overtime pay eligibility for some roles.

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