RN Field Care Manager

· Collaborates with and plays a lead role with Health Care Center and external network PCPs, the Care Team and other practitioners to ensure members are well supported and managed within the Health Home of the Chronic Care Model.

· Collaborates with ASO's, PAC Providers and other Community Services as necessary to ensure appropriate access to service and follow up on the results to such referrals.

· Responsible to manage and coordinate care for an assigned population of Level 3, high risk members.

· Orients new members to the Managed Care program through Welcome and Transition calls.

· Completes assessments and re-assessments timely for members assigned to the Care Team.

· With the member, establishes patient centered long term and short term goals for care and self management.

· With the input of the member, family and medical team, creates an appropriate and timely individual care plan to assist the member to achieve the established goals.

· Maintains current knowledge of MCO benefit structure, policies and procedures related to authorization of services. And is adept at creating a wrap around solution to address member’s needs using appropriate MCO benefits and available ASO and community resources.

· Works to deliver care management services in an efficient and cost effective manner.

· Performs PAC assessments and exception request visits as requested

· Adheres to PAC Manual when delivering PAC assessment or reassessment services.

· Communicates the care plan to the Primary Care Physician, member and others in the Health Home.

· Revises the Care Plan as needed and at a minimum following hospitalization of the member or following the annual re-assessment.

· Meets with patients face to face in the home or at physician appointments to complete assessments and other contacts, as necessary.

· With the support of the Care Team, re-engages the member following hospital admissions and emergency room use through reassessment, coordination of transition of care, including PCP appointment and transportation as needed.

· Monitors the appropriate use of outpatient ancillary services, medication adherence, compliance to PCP visit schedules and results of lab work.

· Provides Transition of Care follow-up visits or calls to patients following change in level of care.

· Provides health education regarding disease process, medications, medication adherence, community resources and benefits.

· Collaborates with AIDS Service Organizations and other community resources, as necessary, to ensure appropriate access to care and services.

· Maintains current clinical knowledge of HIV/AIDS medications and treatment regimens.

· Maintains at least the minimum performance and productivity standards.

· Completes a minimum of three recommended AIDS related in-services, trainings or conferences per year.

o Obtains and maintains HIV/AIDS disease/treatment general knowledge proficiency

· Reports urgent member issues and barriers to care to the Primary Care Provider and the Director of UM/CM, as appropriate.

· Advocates for member needs with medical provider, RN Care Team Manager and community.

· Reports all complaints and grievances per grievance policy.

· Other duties as assigned to ensure team goals are met.