Nurse Case Manager II - Transition OD Care Registered Nurse

Job Responsibilities:

• 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 to complete the rebalancing events and screening assessments.
• Complete telephone or in-person contact to assess the home prior to discharge and identify any environmental support needed to support transition (i.e. ramp, DME installation etc.).
• Conduct an in-person Significant Change Visit with members and Rep if applicable, within 5 days of transition. Coordinate provision of services as needed, establish Plan of Care, and document all actions taken.
• Contact facility’s Business Office once a week to follow-up on members census and will coordinate with Social Services and CM to facilitate discharge.
• Work collaboratively with case managers to identify high risk community members and implement appropriate interventions to prevent lapses or coordinate safe transition (Upon receiving referral)
• Drive enhanced value of health care to increase member satisfaction and retention and drive new membership growth.
• Be involved in at least two community relations events per year
• Engage in building strong relationships that contribute towards member satisfaction and retention

Skills:

• Experience Needed: Candidate must reside in FL and area of coverage
• Minimum 2 years of clinical experience
• Bi-Lingual Spanish/ English required
• Willing and able to travel 75% of their time to meet members face to face and surrounding counties/areas

Education/Experience:

• Education/Licensure: Active, unrestricted and good standing RN license in the state of Florida.
• Associate Degree Required and BSN preferred.