Duties and Responsibilities:
Conducts home assessments (and virtual assessments, as needed) for prospective members and re-assessments of current members using the Uniform Assessment System (UAS); make enrollment and continued eligibility determinations by utilizing clinical expertise and critical thinking skills. As needed, conducts assessments in settings other than home as needed, e.g. skilled nursing facilities or virtually
Completes assessment of service needs per CMT and member's family/caregivers request to determine service needsor any necessary adjustments
Reviews previous nursing assessments/medical notes to determine necessary adjustments/updates in Care Plan and/or to assist with nursing home admission
Conducts in-person Care Management visits in support of person-centered service planning
Liaisons between the member and the CMT; assesses home environment and psychosocial status
Provides feedback to home care agencies and CMT regarding home care issues and contract nurses and aides performance
Provides grass roots, community-based training for frail population care including self-care techniques and prevention strategies
Ensures (prospective) members and significant others/responsible parties understand and are in agreement with enrollment in a managed long-term care plan
Additional duties as assigned
Minimum Qualifications:
New York State RN license
Ability to travel around downstate New York which includes the 5 boroughs, Long Island, Rockland, and Westchester.
For PEDS positions only: 1 year of pediatric clinical field experience and/or experience with families and child serving systems, including child welfare and/or medically fragile/developmentally disabled populations
Preferred Qualifications:
Previous field-based experience assessing, planning, and evaluating member's care by making home or facility visits for intake/reassessments or start of care (SOC) Community Home Health Agency (CHHA) visits
Work experience preferred in one or more of the following areas, geriatrics, home care, discharge planning, case management, and/or medical surgical nursing
Work experience using electronic patient health information (PHI) database usage especially UAS
Knowledge of health insurance, Medicaid, Medicare and MLTCP
Experience working with a frail adult or elderly population with the ability to determine appropriate care plans and services for frail population as well as negotiate initial service plans so that members and families are in agreement
Time management, critical/creative thinking, communication, and problem-solving skills
Language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese
Demonstrated ability handling heavy caseloads
Intermediate Microsoft Word, Excel, and Outlook skills
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
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