Job ID NumberR4220Employment TypeFull timeWorksite FlexibilityHybridJob SummaryAs the Registered Nurse Case Manager you will provide community-based care coordination/management for our client’s members in the state of DelawareJob DescriptionWe are looking for a Registered Nurse Case Manager to provide community-based care coordination/management for our client’s members in the state of Delaware. This position will be a full-time 3 month contract to hire role and hybrid.Due to our end client and project work, this role does not offer visa sponsorship.What You’ll Do Travel to members’ homes, nursing facilities, and other community-based settings to complete face to face needs assessments with subsequent telephonic contact with the member in accordance with state and national guidelines, policies, procedures, and protocols.Assess, plan, coordinate, implement and evaluate care for eligible members with chronic and complex health care, social service and custodial needs in a nursing facility or home and community-based care setting.Coordinate care across the continuum of services and assisting members physical, behavioral, long-term services and supports (LTSS), social, and psychosocial needs in the safest, least restrictive way possible while considering the most cost-effective way to address those needs.Facilitate authorization, coordination, continuity and appropriateness of care and services in community or HCBS.Facilitate transitions to alternate care settings such as hospital to home, nursing facility to community setting using an integrated care team to address the member’s specific needs.Educate members or caregivers regarding health care needs, available benefits, resources and services including available options for long term care community or facility-based service delivery.Provide education, resources, and assistance to help members achieve goals as outlined in their plan of care and to overcome obstacles to achieving optimal care in the least restrictive environment.Develop a plan of care in conjunction with members or caregivers to identify services to meet the member’s specific needs, and goals.Identify resources needed for a fully integrated care coordination approach including facilitating referrals to special programs such as Disease/Chronic Condition Management, Behavioral Health, and Complex Case Management.Collaborate with the member's health care and service delivery team including the DSHP Plus LTSS Member Advocate, ICT, and discharge planners, to coordinate the care needs and community resources for the member in order to maintain the member in the least restrictive safe environment possible.Assist members in developing, implementing and amending a back-up plan for gaps in provider coverage.Ensure approved support services are being provided as outlined in the plan of care. Evaluate the effectiveness of the service plan and making appropriate revisions as needed in accordance with per policy & procedures and state contractual requirements.Assist members in overcoming obstacles to optimal care through connection with community resources, including communicating with providers and formulating an appropriate action plan.Document all case management services and intervention in the electronic health record. Adhere to all company, State and Federal requirements related to privacy practices, HIPAA, and quality performance standards.Perform other duties as assigned/requested.What You'll NeedRequired:Current Registered Nurse, licensed in the state of Delaware5+ years of Case Management and Discharge Planning experience, including experience discharging members from a facility setting.Experience completing Assessments, developing Service Plans and Care PlansExperience collaborating with PCP’s, Occupational Therapists, Behavioral Health, and ProvidersExperience with ordering DME EquipmentExperience educating and providing resources for the member’s Social Determinants.Working flexible hours to meet member’s needsProficiency in PC-based word processing and database documentation (Word, Excel, Internet, Outlook)Reliable transportation daily to be able to travel within assigned territoryAbility to meet regulatory deadlines.Has a dedicated workspace used only for business purposes and is able to comply with all telecommuter policies.Experience in geriatric special needs, behavioral health, home healthUnderstanding of the importance of cultural competency in addressing targeted populations.Experience with electronic documentation system(s)Experience with cost neutrality and budgetingMust be willing to travel throughout the state (may only need to travel 2-3 times a week depending on schedule)Must be able to communicate clearly to members - will be tasked with conducting assessments with members over the phonePreferred:Certified Case Manager (CCM)Licensed Bachelor’s Social Worker (LBSW)Licensed Master’s Social Worker (LMSW)Licensed Clinical Social Worker (LCSW)Experience working with HIV/AIDS populationExperience working with behavioral health populationExperience working with developmental disabilities populationMedicare and Medicaid experiencePhysical DemandsAbility to safely and successfully perform the essential job functions consistent with the ADA and other federal, state, and local standardsAbility to move about to accomplish tasks or move from one worksite to anotherRegularly access low and high spaces that may be at irregular angles such as under a deskAbility to conduct repetitive tasks on a computer, utilizing a mouse, keyboard, and monitorMust be able to communicate with customers/team members over the phone and in person Must be able to wear personal protective gear such as a helmet, goggles, mask, and protective footwear throughout the dayReasonable Accommodation StatementIf you require a reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employment selection process, please direct your inquiries to or (888) 824 – 8111.Equal Employment Opportunity Policy StatementIt is the policy of CAI not to discriminate against any employee or applicant due to race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or being a protected veteran. It is also the policy of CAI to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or being a protected veteran, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Employees and applicants of CAI will not be subject to harassment due to race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or being a protected veteran. Additionally, retaliation, including intimidation, threats, or coercion, because an employee or applicant has objected to discrimination, engaged or may engage in filing a complaint, assisted in a review, investigation, or hearing or have otherwise sought to obtain their legal rights under any Federal, State, or local EEO law is prohibited.