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Responsible for overall care management and quality of care for participants.  Uses specialized knowledge of physical health, aging and loss, medication management and potential negative side effects, depression, challenging behaviors, Alzheimer’s Disease/Dementia, depression, behavioral health, and issues related to accessing and using durable medical equipment as appropriate.  Appropriately documents any new findings in the member’s care management record.

Provides care coordination in a manner that is sensitive to age, gender, sexual orientation, cultural, linguistic, racial, ethnic, religious backgrounds, and congenital or acquired disabilities.



  • Participates and represent the Community Health Nurse (CHN) in all IDT meetings.

  • The Care Manager will review all nursing documentation for quality and addresses any deficiencies.

  • The Care Manager will review the UAS and the UAS analyzer system daily, run reports and follow up with the nurses on the accuracy of their assessments.

  • Have regular meetings with their nurses to review case load, participant status and documentation.

  • The Care Manager (CM) communicates with the CHN on a regular ongoing basis to coordinate a continuum of care consistent with the Member’s health care needs and goals.  This care plan supports the Member in attaining and/or maintaining an optimal functional and health status.

  • Coordinates the IDT meetings for the Members assigned to their case list.

  • In coordination with the IDT, arranges, coordinates, and authorizes the provisions of appropriate services to meet identified member specific needs (such as assistance with the Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), housing, home-delivered meals, and transportation) and when approved by the IDT, may authorize a range and amount of community based services.

  • Implements specific care management activities and/or interventions that lead to accomplishing the participants goals.

  • Provides care management services across sites and collaborates with appropriate team members, facility, discharge planner and/or home care coordinator when members are transitioned between care settings.

  • Documents services in accordance with CLHC standards and federal/state regulations

  • Coordinates, facilitates, and arranges for long term care services in nursing homes, rehab facilities, etc. as needed.

  • Collaborates with PCP and other Specialty physicians and specialty-based services and members of IDT regarding any changes in participants condition to secure, arrange and coordinate all resources for implementing optimal care.

  • Provides or arranges for ongoing Skilled nursing care and other skilled disciplines, service authorization and periodic assessment re assessment and evaluation of services

  •  Monitors care management activities, services, and member’ responses to interventions, to determine the effectiveness of the plan of care and the utilization of services and implements changes and adjustments to meet needs and resolve goals

  • Evaluates the effectiveness of the plan of care in reaching desired goals and outcomes, makes modifications or changes in the plan of care based on changes in the member’s health, as needed.

  • Fiscally responsible in providing services based on member’s needs.

  • Maintains up-to-date knowledge about current health related issues, procedures, evidence based clinical practices guidelines, medications and impacting health and practice standards.

  • Serves as the Director of Patient Services (DPS) for the LHCSA.

  • Serves as Manager on call during non-operational hours of the physical sites.

  • Recommends and contributes to improvements in services, programs, policies, and procedures, to ensure optimum care and services to members.

  • All other duties as assigned.

Performance Standards

  • Performs consistent with organization’s mission and philosophy.

  • Performs job responsibilities according to organization’s policies.  Seeks clarification when needed.

  • Assumes responsibility for assignments given, seeks supervision appropriately, and is accountable for work performance.  Meets productivity guidelines.

  • Maintains proper documentation (updated, timely, legible) related to patient care, whether paper or electronic.

  • Maintains HIPAA standards and confidentiality of PHI.

  • Supports staff, student, and volunteer orientation and ongoing inservice education as requested.

  • Supports organizational activities by participating in quality improvement activities, special projects, internal and/or external committees, community activities and other duties as assigned.

  • Serves as role model for peers and colleagues.

  • Assumes responsibility for professional growth and development; maintains and upgrades professional knowledge and practice skills.

  • Treats other CenterLight employees respectfully and facilitates an environment of teamwork.

  • Initiates, if appropriate, incident reporting process, and participates in incident investigation and reporting as applicable.

  • Performs general office duties in connection with job responsibilities, including but not limited to photocopies, faxing, typing, filing, and phone calls.

Service Standards

  • Makes the needs of participants their central focus, and finds innovative ways to provide an exceptional experience.

  • Develops and maintains positive “customer” relationships (“customer” is defined as co-workers, participants, visitors, vendors, supervisors).

  • Communicates with customers in a caring, helpful, considerate and culturally sensitive manner.

  • Demonstrates a thorough understanding of customer needs and wants and attempts to anticipate and meet customer needs.

  • Suggests and implements customer-centered service improvements.

  • Encourages customers to engage with CenterLight employees and CenterLight activities.

  • Utilizes service recovery techniques to resolve issues quickly and to the customer’s satisfaction.  Immediately reports customer dissatisfaction to IDT for follow-up.

Managerial Standards

  • Ensures that direct reports conduct their duties according to applicable rules and regulations as well as organization’s policies and procedures.

  • Evaluates the work performance and competency of direct reports.  This includes ongoing informal feedback/counseling/support and completion of annual performance reviews.

  • Holds staff accountable for their individual performance.

  • Follows organization’s policies regarding disciplinary action.  Engages Human Resources as needed for guidance on disciplinary actions and terminations.

  • Develops individual professional development plans with direct reports, including the identification of in-service training needs and interests.

  • Investigates and resolves employee grievances and complaints.  Engages with Human Resources as appropriate.

  • Participates in the annual budgeting process for department; manages departmental budget; approves departmental expenditures.


Minimum: $100,000.00

Maximum: $112,000.00


  • Education: Degree from an NLN accredited school of nursing (RN, BSN preferred). Successful completion of an accredited Nursing Program required. Baccalaureate degree highly preferred.Completed NYSED approved infection control coursework.  A minimum of 8.0 education contact hours that may include contact hours of mandatory training requirements such as infection control coursework.

  • Case Management Certification required.

  • Experience: Minimum of 2 years of administrative experience in a management capacity in a certified home health agency (CHHA), long term home health care (LHCSA), acute care, medical surgical, and/or critical care, nursing home experience, diagnostic & treatment clinic preferred.

  • Customer Service experience required.

  • Managed long term care insurance experience beneficial.

  • Minimum of 1 year experience working with the elderly.

  • Supervisory experience required.

  • License Registration: Current active and unrestricted license and registration in New York State required as a Registered Nurse.

  • Language: Bilingual preferred.

  • Physical: Works inside at office locations and outside in varied weather conditions in all areas of the community, using private or public means of transportation.   Must be able to walk to participant homes as well as upstairs (if no elevator) to their individual unit. Ability to sit/stand for extended periods of time. Ability to ascend/descend Possess and maintain good physical stamina and mental health, including satisfactory health clearance as required by NYS regulations and Agency policy. Able to physically perform job duties, completed pre-employment and annual physical. Potential exposure to health hazards.

  • Other: Demonstrate proficient typewriting skills.

  • Takes initiative, is resourceful, proactive, creative, innovative and independent. Is self-directed with ability to work with or without supervision.

  • Good organizational, observation, communication and judgment skills.

  • Demonstrated ability to establish good rapport with participants and peers is essential.

  • Tactful and courteous.

  • Pleasant telephone manner.

  • Must be able to work weekends.

  • Excellent written and verbal communication.

  • Professional attitude.

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