Location: Rochester,NY, USA
Duties and Responsibilities:Conducts in-person (and virtualassessments, 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, e.g. skilled nursing facilitiesor virtuallyCompletes assessment of service needs per CMT and member's family/caregivers request to determine service needs or any necessary adjustmentsReviews previous nursing assessments/medical notes to determine necessary adjustments/updates in Care Plan and/or to assist with nursing home admissionConducts in-person Care Management visits in support of person-centered service planningLiaisons between the member and the CMT; assesses home environment and psychosocial statusProvides feedback to home care agencies and CMT regarding home care issues and contract nurses and aides performanceProvides grass roots, community-based training for frail population care including self-care techniques and prevention strategiesEnsures (prospective) members and significant others/responsible parties understand and agree with enrollment in a managed long-term care planFulfills all scheduling activities to ensure prospects/ members/ caregivers are scheduled and are aware of the scheduled visitsBe able to fully participate in orientation, training and meeting activities as the role requiresAdditional duties as assignedMinimum Qualifications:New York State RN licenseAt least 1 year of prior UAS Assessment Nurse experienceAbility to travel within the BronxPreferred 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) visitsWork experience preferred in one or more of the following areas, geriatrics, home care, discharge planning, case management, and/or medical surgical nursingWork experience using electronic patient health information (PHI) database usage especially UASUnexpired NY state drivers license or NYS IDKnowledge 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 agreeTime management, critical/creative thinking, communication, and problem-solving skillsLanguage preferences - Spanish, Russian, French, Creole, Mandarin, CantoneseDemonstrated 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.