LE0006 MSO of Puerto Rico, LLC

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The Care Manager is responsible to assess all referred cases, plan, implement, perform interventions, coordinates services, monitor, and evaluate the options and services including psychosocial elements for high risk members, in an effort to ensure the continuity of care for short and long term. Assumes leadership across the continuum of care and promotes effective utilization of resources to obtain cost-effective outcomes. Coordinates care across care settings for beneficiaries and providers. Deliver medical, mental health and social services to beneficiaries when the need is identified through health risk assessment.

RESPONSIBILITIES

1. Reviews the High Risk-High Cost, Emergency Room Utilization and High Risks Assessment Reports, referrals from concurrent review nurses, providers and internal departments, among others. 2. Performs comprehensive health assessment for identified members that meet criteria for admission into Case Management.3. Obtain necessary information in order to identify needs, problems, and barriers to address member’s needs. 4. Assess the following areas:a. Health Status including conditions-specific issuesb. Clinical History including medicationsc. Activities of Daily Living d. Behavioral health status, including cognitive functionse. Psychosocial issuesf. Cultural and linguistic needs, preference or limitationsg. Visual and hearing needs, preference or limitationsh. Caregiver resources and involvementi. Available benefitsj. Available community resourcesk. Life Planning activities5. Refers cases evaluated to Health Education, Telemonitoring, Behavioral Health and Disease Management Programs as needed and or when severity change.6. Develops an individualized and efficient care planning process, implementing actions oriented to realistic and measurable goals.7. Performs Home visits when: member’s needs assessments requires addressing their needs in an effective manner, when telephonic assessment can't be performed due to some limitation, lack of information provided by caregiver or family member and/or as requested by CM Supervisor, or Interdisciplinary Care Team.8. Analyze the information objectively focusing on trends or patterns to anticipate care or cost impact services. 9. Considers the potential alternatives, focus on the best treatment of care, minimizing unnecessary steps to achieve cost-benefit effective outcome.10. Considers the potential alternatives including advocate and evidence exception of benefits needs when is medically necessary. 11. Works closely with Primary Care Physician, Inpatient Department, Discharge Planning Unit and other departments, in order to identify risk members and or facilitate care transitions proactively. 12. Communicate member’s change of status to the Primary Care Physician to evaluate health care alternatives for improvement.13. Implements the care plan promoting timely provision of: coordination of services, education and utilization of resource in order to prevent adverse event on members. 14. Performs prior authorizations process as required to meet member’s needs.15. Performs authorizations determined by Medical Director, coordination, and utilization of the cases that requires services out of service area. 16. Initiates plan modifications as necessary and re-evaluation to accommodate changes in treatment plan, or when anticipating treatment or services complications.17. Monitor member’s progress according to established care plan and makes adjustments as required.18. Provides verbal education and/or educational material to member according to their conditions and/or specific needs.19. Performs liaison function by communicating with the member’s physician(s) when significant adjustments are necessary or other disciplines and coordination are incorporated to achieve the goals.20. Maintains electronic record documentation of all interventions performed, variances on care, and other important information to demonstrate the current follow ups, clinical quality outcomes and cost-effective impact of case management.21. Develops and maintains relationship with outside organizations/community agencies.22. Perform referrals to needed and available community resources, connect families and/or provide follow-up with clients and agencies as appropriate to document use/success of referral.23. Attends and handle incoming calls from primary care physician, providers and members courteously and professionally.24. Participates on meetings, as appropriate, with the multidisciplinary team, primary care physician, and other participating personnel to update all relevant team regarding the patient’s status or modifications to the care plan.25. Participates in round clinics discussion with Multidisciplinary team such as program medical director as well as other disciplines, documenting all recommendations, and outcomes. 26. Maintains adequate workload as established 27. Participate in regular staff meetings, staff training, supervisory working sessions, and accept the responsibility for aiding the development of positive team relationships as requested.28. Performs productivity reports. 29. Work to adhere to the department policies related to the care of the SNP’s members and the following is required:o Attend all required Trainings related to the Model of Care (MOC) especially in areas of Care Management, ICP, ICT and health assessment.o Notifies supervisor of any processes not in compliance with the SNP’s policies and MOC requirements.o If doesn’t complete the required annual trainings, may not perform his/her clinical duties and care management functions until the training is completed.30. Adhere to agency policy, procedures and the professional code of ethics.31. Conduct and/or participate in both formal and informal meetings with the MSO Medical Director and external vendors as required.32. Maintain contact with patients and provide follow up to their care needs. Obtain any feedback and recommendations that might be addressed to improve the process.33. Collaborates with the interdisciplinary team to continuously improve, patient/customer satisfaction and patient care outcomes.34. Assures the standards of care process while the patient is in an Inpatient care setting.35. Establishes a system to maintain effective communication with all facility, vendors including scheduled regular staff meetings with recorded minutes.36. Authorizes and/or facilitates access to specialist and therapist.37. Advocates, informs, and educates beneficiaries on services and benefits.38. Triages beneficiaries care needs.39. Performs all other duties as assigned by supervisor.

EDUCATION AND EXPERIENCE

• Bachelor or Master’s Degree in Nursing• Current certification from a nationally recognized Board in Nephrology or Hemodialysis, preferred. • Current Puerto Rico professional license and Collegiation• Certification in Care Management preferred.Minimum of 3-5 years’ experience related to health care fields, dialysis nursing, case management, acute care or ambulatory settings, home health care, or managed care setting.

GENERAL ABILITIES AND KNOWLEDGE

1. Current Puerto Rico driver's license and vehicle available to drive between locations when needed.2. Ability to work independently and apply nursing clinical judgment in making decisions.3. Demonstrated ability to function in a leadership position and to perform in new and emergent situations with judgment.4. Computer literate5. Ability to perform statistics reports

LANGUAGE SKILLS

Bilingual (English to Spanish). Ability to read, analyze, and interpret general business periodicals, operating and maintenance instructions, procedure manuals, professional journals, technical procedures, or governmental regulations.

Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

MATHEMATICAL SKILLS

Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

REASONING ABILITY

Ability to define problems collects data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

PHYSICAL AND MENTAL DEMANDS

Requires sitting and standing associated with normal office environment. Regularly talks and hears. This position requires that weight be lifted or force be exerted up to 10 pounds.

ENVIRONMENTAL AND WORKING CONDITIONS

Normal office environment. The noise is typically moderate. Evening or weekend work, as necessary.

If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!

Innovacare, Inc. is the leading provider of healthcare management in North America. Through two it’s main ways, Medicare Advantage and the provider network, we are committed to healthcare, creating models that are sustainable, cost-effective, and fully integrated with the most advanced technologies. Innovacare, Inc. combines innovation and quality care to create progressive, value-based models, even for the neediest patient populations. Our leadership team, with its vast years of combined experience in managed care and care delivery, is made up of leading experts with proven experience to help healthcare organizations effectively meet and exceed the growing demands of our industry.

InnovaCare Health's foundation was laid by President and CEO Richard Shinto, M.D., in 1998, when he joined North American Medical Management (NAMM) in California. Over the next 10 years, the company continued to grow, acquiring MMM Healthcare in Puerto Rico. In December 2012, the management team successfully sold select NAMM properties and officially formed InnovaCare Health to operate the remaining subsidiaries, including MMM. MMM Holdings, is a conglomerate of companies that work on Puerto Rico's business strategies, both for Medicare Advantage beneficiaries, through Medicare y Mucho Más (MMM), and for the beneficiaries of the government health plan with MMM Multihealth. Through InHealth Management, it manages the in-hospital care of the beneficiaries, while the specialized clinics, MMM Vita Care, serve members with chronic conditions. On the other hand, MSO of Puerto Rico supports medical groups, providers and other entities in the health industry, while Castellana Physicians Services is a medical group dedicated exclusively to providing services for the elderly and disabled population in Puerto Rico.

At the same time, the main company manages Medicare and Much More, a Medicare Advantage population health plan with a presence in Miami-Dade, Broward and Palm Beach counties. With a Mobile Application that allows members to check the status of their pre-authorizations, access their provider directory and schedule their future medical visits, Medicare and Much More integrates technology as a tool to improve the member experience. Also, the plan will ensure the health of members, during and after natural disasters. Through the Florida MMM Line of Care, as a Part D sponsor, you will ensure that the member has adequate access to their covered Part D drugs.

Orlando Family Physicians, a group of clinics that provide comprehensive care services in the state of Florida, is another of the companies managed by Innovacare, Inc. With more than 20 years of service in the Central Florida community and more than 100,000 patients cared, Orlando Family Physicians offers the personalized treatment and care that the patient deserves. With a track record that proves excellent customer service, we are proud that the largest Hispanic medical group in Central Florida has joined us. Our constant growth is the best witness we have to tell that things are being done well, so it is our commitment to continue on this path.

Innovacare, Inc. es el proveedor líder de manejo de servicios de salud en Norteamérica. A través de dos principales vías, Medicare Advantage y la red de proveedores, estamos comprometidos al cuidado de la salud, creando modelos que son sostenibles, costo-efectivos y completamente integrado a las tecnologías más avanzadas. Innovacare, Inc. combina innovación y atención de calidad para crear modelos progresivos y basados en el valor, incluso para las poblaciones de pacientes de mayor necesidad. Nuestro equipo de liderazgo con sus vastos años de experiencia combinada, en atención administrada y prestación de atención, está formado por expertos preeminentes con la experiencia comprobada para ayudar a las organizaciones de atención médica a satisfacer y superar eficazmente las crecientes demandas de nuestra industria.

Las bases de InnovaCare Health fueron establecidas por el presidente y CEO Richard Shinto, M.D., en 1998, cuando se unió a North American Medical Management (NAMM) en California. Durante los próximos 10 años, la compañía continuó creciendo, adquiriendo MMM Healthcare en Puerto Rico. En diciembre de 2012, el equipo de gestión vendió con éxito propiedades selectas de NAMM y formó oficialmente InnovaCare Health para operar las filiales restantes, incluida MMM.

MMM Holdings, es un conglomerado de compañías que trabaja las estrategias de negocio de Puerto Rico, tanto para Medicare Advantage, a través de Medicare y Mucho Más (MMM), como para los beneficiarios del plan de salud del Gobierno con MMM Multihealth. A través de InHealth Management maneja el cuidado intrahospitalario de los beneficiarios, mientras que, las clínicas especializadas, MMM Vita Care, atienden afiliados con condiciones crónicas. Por otro lado, MSO of Puerto Rico apoya grupos médicos, proveedores y otras entidades en la industria de la salud, mientras Castellana Physicians Services es un grupo médico dedicado exclusivamente a proveer servicios para la población de edad avanzada y discapacitada en Puerto Rico.

A su vez, la compañía matriz maneja Medicare and Much More, plan de salud para la población Medicare Advantage con presencia en los condados de Miami-Dade, Broward y Palm Beach. Con una Aplicación Móvil que permite a los afiliados verificar estatus de sus pre-autorizaciones, acceder su directorio de proveedores y agendar sus futuras visitas médicas, Medicare and Much More integra la tecnología como una herramienta para mejorar la experiencia del afiliado. También, el plan velará por la salud de los afiliados durante y después de desastres naturales. Por eso, a través de la línea de cuidado MMM de Florida, como patrocinador de la Parte D, se asegurará de que el afiliado tenga acceso adecuado a sus medicamentos cubiertos de la Parte D.

Orlando Family Physicians, grupo de clínicas que brindan servicios para el cuidado integral en el estado de la Florida, es otra de las compañías manejadas por Innovacare, Inc. Con más de 20 años de servicio en la comunidad de Florida Central y más de 100.000 pacientes atendidos, Orlando Family Physicians ofrece el tratamiento personalizado y la atención que el paciente merece. Con una trayectoria que prueba un excelente servicio al cliente, estamos orgullosos de que el grupo médico hispano más grande en Florida Central se haya unido a nosotros. Nuestro constante crecimiento es el mejor testigo de que las cosas se están haciendo bien por lo que es nuestro compromiso continuar por ese camino.