Overview • Provide telephonic assessments of members’ medical, psychosocial, physical, and spiritual needs to ensure comprehensive care planning. • Develop, implement, and monitor person-centered service plans, ensuring continuity of care across healthcare settings. • Collaborate with interdisciplinary care teams, primary care providers, members, and specialists to address healthcare needs. • Utilize benefit structures and community-based resources to meet member needs effectively. • Educate members on disease processes, preventive health measures, and quality-of-life interventions. • Conduct initial and scheduled telephonic assessments, reviewing data to develop and update service plans. • Respond to changes in member conditions by revising service plans and communicating updates to the care team. • Participate in interdisciplinary care team meetings to discuss member conditions and care strategies. Key Responsibilities & Duties • Complete telephonic assessments and review visit data as assigned by the supervisor. • Develop person-centered service plans based on completed assessments and departmental workflows. • Revise and update service plans in response to changes in member conditions or sentinel events. • Collaborate with interdisciplinary teams to ensure effective care delivery and member satisfaction. • Educate members about healthcare processes, preventive measures, and quality-of-life improvements. • Adhere to CMS and DOH regulations in care management practices. • Present cases and updates at interdisciplinary care team meetings. • Utilize Medicare and Medicaid knowledge to optimize member care plans. Job Requirements • Graduate of an accredited nursing program; Bachelor’s degree (BSN) preferred. • Current RN New York State license; CCM certification preferred. • Minimum three to five years of nursing experience in long-term care, managed care, home care, geriatrics, or hospice. • Prior experience in interdisciplinary service delivery environments preferred. • Working knowledge of Medicare and Medicaid regulations essential. • Proficiency in developing and implementing person-centered service plans. • Bilingual proficiency in Mandarin or Cantonese highly desirable. • Ability to work remotely with occasional hybrid training schedules.