JOB RESPONSIBILITIES
- Perform initial in-home pre-evaluation of patients that includes evaluation of health status, strengths, care needs, and preferences and guides the development of individualized long term care service plans
- Review consumer medical documentation and or health referral forms, as relevant to the case
- Enter evaluation data into electronic UAS evaluation form and transmit, as required
- Document any concerns, conflicting information, other issues that surface during the evaluation process
- Emphasize continuity of care, thus reducing or eliminating fragmentation, duplication, and gaps in treatment plan
- Discuss with consumer health care options, supports needed, service vendor options and waiver options
- Initiate communication between the Call Center and eligible consumers for enrollment into a managed care health plan
- Enhance communication and collaborative relationships with interdisciplinary care team members to improve care coordination and facilitate service delivery
- Collect quality review data and any required documentation to support outcome measurements and record case notes into the customer relationship manager system
- Identify opportunities for health promotion and consumer illness prevention
- Maintain a comprehensive working knowledge of community resources, payor requirements, and network services for target population
- Meets all standards established for this position as outlined in the corresponding annual performance criteria and bonus template for this position.
- Performs other duties as may be assigned by the Regional Nurse Manager or other project management.
Qualifications:
Two years of experience working in a home environment as a nurse in the last 10 years
Current RN Licensure in New York State
Graduate of an accredited nursing program
Experience conducting assessments in UAS (role 40 or 45), especially in the last 365 days preferred
Experience with the geriatric population, chronic diseases, especially in the home setting preferred