Responsibilities Evaluates the service needs of the most complex or high risk/high acuity members and recommends a plan for the best outcome Develops and continuously assesses ongoing long-term care plans / service plans and collaborates with care management team to identify providers, specialists, and/or community resources needed to address member's needs Coordinates and manages as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or services Monitors care plans/service plans and/or member status, change in condition, and progress towards care plan/service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals/needs Monitors member status for complications and clinical symptoms or other status changes, including assessment needs for potential entry into a higher level of care and/or waiver eligibility, as applicable Reviews member data to identify trends and improve operating performance and quality care in accordance with state and federal regulations Reviews referrals information and intake assessments to develop appropriate care plans / service plans Collaborates with healthcare providers as appropriate to facilitate member services and/or treatments and determine a revised care plan for member if needed Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and clinical guidelines Provides and/or facilitates education to long-term care members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefits Acts as liaison and member advocate between the member/family, physician, and facilities/agencies Educates on and coordinates community resources. Provides coordination of service authorization to members and care managers for various services based on service assessment and plans (e.g., meals, employment, housing, foster care, transportation, activities for daily living) May perform home and/or other site visits (e.g., once a month or more), such as to assess member needs and collaborate with resources, as required Partners with leadership team to improve and enhance quality of care and service delivery for long-term care members in a cost-effective manner May precept clinical new hires by fostering and building core skills, coaching and facilitating their growth, and guiding through the onboarding process to upskill readiness May provide guidance and support to clinical new hires/preceptees in navigating within a Managed Care Organization (MCO) and provides coaching and shadowing opportunities to bridge gap between classroom training and field practice In field visits to the members homes - Candidates must reside in La Feria, TX & Harlingen, TX & San Benito, TX Candidate Requirements Education/Certification Required: Requires Graduate from an Accredited School of Nursing or a Bachelor's degree and 46 years of related experience Preferred: Bachelor's degree in Nursing preferred Licensure Required: RN - Registered Nurse - State Licensure and/or Compact State Licensure required Preferred: Years of experience required: 46 years of related experience case management, private duty nursing, pediatric population.