RN Care Manager (DSNP)

Hello, we’re Belong. We partner with regional payers to deliver Medicare Advantage and Special Needs Plan products. With a dual focus on data-driven, proactive clinical intervention and unwaveringly empathetic patient experience, Belong has completely reimagined health insurance for seniors and other Medicare-eligible individuals who have been disregarded and deprioritized for far too long. We believe that only by recognizing individuals can we make communities strong. Belong Health. Kinder, more supportive care. SUMMARY The Registered Nurse (RN) Care Manager for Belong Health's DSNP program is responsible for providing comprehensive, member-centered care management services for Medicare beneficiaries with complex medical, behavioral health, and social needs. This role applies care management principles to assess member needs, develop and implement individualized care plans, coordinate services across the continuum of care, and maintain collaborative relationships with provider practices, community-based organizations, caregivers, and the Belong Health team. ESSENTIAL JOB DUTIES AND RESPONSIBILITIES Responsible for providing clinical oversight to medically complex Medicare beneficiaries Orient new members to the Belong Health DSNP program and educate the member and/or caregivers on care management services. Advocate, empower, inform, and educate beneficiaries on self-management techniques. Conduct assessments to identify barriers and opportunities for intervention. Complete health risk assessments, reassessments, and other clinical evaluations in accordance with program requirements. Identify members requiring intensive care management interventions and coordinate appropriate clinical, behavioral health and community-based services. Develop and implement an individual care plan (ICP). Monitor member progress toward care plan goals and revise interventions based on changing clinical or social needs. Lead interdisciplinary care team meetings. Collaborate with provider, social workers, discharge planners, and community-based service providers to coordinate care and achieve care plan goals. Support transitions of care activities including post-discharge outreach, medication reconciliation support and coordination with providers and caregivers. Document all care management activities in the appropriate system in accordance with internal and established documentation procedures. Work directly with members, their families and/or advocates, providers, and community service organizations on an ongoing basis to coordinate care and reduce barriers to care. Utilize population health, risk stratification and care management technology platforms to prioritize outreach and interventions. Promote a culture of accountability and performance to both meet and exceed personal service vision goals and ensure timely and satisfactory resolution of highly complex, specialized, and non-routine customer issues. Other duties as assigned. SUPERVISORY RESPONSIBILITIES This role does not have supervisory responsibilities. REQUIRED PROFESSIONAL EXPERIENCE AND QUALIFICATIONS Working knowledge of Medicare and Medicaid programs and experience with regulatory requirements and reporting. Proficient in navigating multiple systems; demonstrated PC skills using Microsoft applications. Two (2) or more years’ experience in a health plan, health care organization, Community Based Organization, or social services environment. Experience supporting Medicare, Medicare Advantage, Medicaid, Dual Eligible Special Needs Plans (DNP), or other complex populations. Experience delivering care management services in a telephonic and/or virtual environment. Understanding of needs and dynamics of elder care services, disadvantaged, disengaged populations. Knowledge of care coordination, transitions of care, motivational interviewing, and person-centered care planning principles. Experience participating in cross departmental projects and policy and procedure changes, including coor