Job Description
ElderServe Health is a mission-driven, nonprofit managed care organization serving the New York metropolitan area. ElderServe provides long-term services and supports to more than 20,000 older adults and adults with disabilities across New York City, as well as Westchester, Nassau, and Suffolk Counties. ElderServe primarily serves a frail and elderly membership who is predominantly dual-eligible and enrolled in Medicaid managed long-term care, Medicare-only and integrated Medicaid-Medicare plans. The CareSource and ElderServe affiliation addresses these critical long-term care needs to help members be as healthy and independent as possible. Job Summary: The Nurse Care Manager is responsible for providing care coordination including in-home assessment, planning, facilitation, advocacy and authorization of covered plan services to meet the member's health needs while promoting quality cost effective outcomes. Essential Functions: Ensures consistent care along the entire health care continuum by assessing and closely monitoring members' needs and status. Authorizes covered services and coordinates care regardless of payer. Collaborates and communicates with member/family/caregivers, primary care practitioners, and the interdisciplinary team. Works with member/family to maintain the most independent living situation possible Assesses, plans and provides continuous care management across all venues of care, including hospital, sub-acute, long-term and home settings. Regularly assesses members for ongoing eligibility for services based on the specific plan's eligibility criteria. Performs home visits as required to assess members' living situation, cultural influences, functional and cognitive needs. Collaborates with the primary care physician and Inter-Disciplinary Team (IDT) to develop the Patient Centered Service Plan for the member. Ensures appropriate