Location: Monsey,NY, USA
Duties and Responsibilities:Conduct home assessments 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 facilitiesComplete assessments of service needs per Care Management Team and member's family/caregivers request to determine service needsor any necessary adjustmentsReview previous nursing assessments/medical notes to determine necessary adjustments/updates in Care Plan and/or to assist with nursing home admissionConduct in-person Care Management visits in support of person-centered service planningLiaison between the member and the CMT; assesses home environment and psychosocial statusProvide feedback to home care agencies and CMT regarding home care issues and contract nurses and aides performanceProvide grass roots, community-based training for frail population care including self-care techniques and prevention strategiesEnsure (prospective) members and significant others/responsible parties understand and are in agreement with enrollment in a managed long-term care planAdditional duties as assignedMinimum Qualifications:New York State RN licenseAbility to travel in and around Bronx, New YorkUnexpired NY state drivers license or NYS DMV IDPreferred Qualifications:GeriatricsHome CareDischarge PlanningCase ManagementMedical Surgical NursingElectronic patient health information (PHI) database experienceKnowledge of health insurance, Medicaid, Medicare and MLTCPExperience 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 agreementTime management, critical/creative thinking, communication, and problem-solving skillsField experience assessing, planning, and evaluating member's/patients careDemonstrated ability handling heavy caseloadsIntermediate Microsoft Word, Excel and Outlook skillsWE 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.