This position has 2 components:
- Completion of a Uniform Assessment (UAS) of the Manage Long term Member’s clinical, cognitive, functional, psychological and social needs. Based on the assessment, the Nurse Assessor completes a comprehensive plan of care that is communicated to the member, PCP, PCW vendor, and the Care Management team. All documentation and clinical information is communicated on a timely basis to the Care Management team for in-office care coordination and additional care plan development. All requests for service assigned to the Nurse Assessors are evaluated and recommendations are communicated to the Care Management team.
- Evaluates/ directs and supervises home care workers ( PCA/HHA) providing in-home care services using LHCSA protocols.
Essential Functions and Responsibilities under Care Management:
- Conducts and completes Uniform Assessments (UAS) in the member’s home within DOH regulatory timeframes and MLTC plan’s protocols. Nursing Home UAS visits are made as required.
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- Completes all urgent requests for service. Communicates safety issues, changes in condition, or clinical care needs to the PCP and Care Management team upon completion of assessment on same day of identification.
- Assesses member in the home to evaluate for requests for service.
- Utilizes Medicare, Medicaid, and internally developed criteria to assess member’s eligibility for requested service.
- Submits recommendation and supporting documentation to the Care Management team within 1 business day of completed assessment, keeping within regulatory and unit timeframes
- All urgent issues are communicated verbally and or via email to the appropriate care management team with cc to supervisor.
- Obtains orders from the PCP as needed (including skilled home care) and communicates information to the care management team
- Creates/updates an individualized, comprehensive plan of care for the member, based on assessment.
- Validates initial plans of care and communicates changes as appropriate to the Care Management team.
- Completes all required documentation which addresses clinical, social, psychological, and preventive health needs of the member that are identified through the assessment/re-visit process and communicated with member’s PCP.
- PCW Plan of care is created or updated during of assessment/re-visit, and reviewed with the member, member’s representative and PCW. Comprehensive Plan of care is communicated to the member’s PCP and vendor as per plan’s protocols. .
- Communicates and submits all completed assessments and completes and submits all required documentation within 3 business days of visit. Corrections to notes will be submitted within 1 business day.
- Communicates inability to make assessment visits i.e. out of area, hospitalized, and refused to the care management team for follow-up in a timely manner..
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- Participates in inter-disciplinary team meetings, educational programs and other meetings as needed.
Essential Functions and Responsibilities under IVCI-LHCSA:
- Evaluates/ Directs and supervises home care workers including Personal Care Workers and Home Health Aides under LHCSA protocols and standards.
- Participates in the remediation or discipline of aides based upon performance and /or failure to meet standards of services/care set by the agency.
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- Develops a Paraprofessional Plan of Care for those individuals who require home care services based on the home care assessment assuring that the patient/client is involved and agrees with the activities defined in the plan of care.
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- Ensures that the established Paraprofessional Plan of Care is implemented by the assigned home care worker and communicates the observed ability and/or performance of the home care worker with the Service Coordinator of the LHCSA
- Assesses need and communicates appropriate professional and ancillary services for patients through the use of community resources.
General Essential Functions and Responsibilities:******
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- Meets visit productivity standards of the agency. Plans member visits by using appropriate time management skills. Demonstrates flexibility in modifying visit schedule to meet the needs of the agency.
- Customer Service:
- Appropriate customer interactions.
- Acknowledges the rights of patients and customers, treats all customers in a consistent manner.
- Takes action to solve problems before being asked.
- Devotes all attention and resources to provide the best customers service possible.
- Shows sensitivity and understanding of others’ concerns.
- Communication: Verbal and Written
- Chooses words that are easy to understand, explains in unfamiliar, technical jargon when necessary.
- Information is detailed accurately.
- Adapts communication content and style for maximum effectiveness with different audiences. .
- Written documentation is clear and concise.
- Collaboration/Cooperation:
- Works with others toward shared goals.
- Establishes and maintains interpersonal relations with colleagues and external customers, following up as required, etc.
- Offers assistance and shares in departmental responsibilities.
- Keeps all interested parties informed of relevant or pertinent developments.
- Abides by all Isabella and/or MLTC Policies and Procedures.
- Dependability:Can rely on this employee to perform assignments as necessary.
- Follows manager’s instructions and responds to requests.
- Consistently takes action that is most appropriate for achieving departmental and hospital goals.
- Keeps to deadlines and commitments.
- Meets punctuality guidelines.
- Critical Thinking
- Demonstrates ability to evaluate information and situations in order to make independent decisions and to identify critical issues.
Qualifications:
RN graduate of an accredited school of nursing required, Baccalaureate Degree preferred
A minimum of one year's experience in nursing of which Community Health, geriatrics, long term care, hospice, Managed Care experience, or related field is preferred.
- Certification and Licensure:
Registered Professional Nurse (RN) licensed to practice in New York State.
NYS ID to access UAS-NY assessment
Physical Requirements and Working Environment:
- Physical Demands: Walks, sits, stands, reaches visual and aural acuity; New York State Driver's License and automobile strongly preferred.
- Mental Demands: Ability to remain calm and rationale when dealing with angry and/or agitated patients.*
- Working Conditions: travels to member’s homes, where there there may be walk-up stairs.*
All your information will be kept confidential according to EEO guidelines.
