Duties and Responsibilities:

• Conducts in-person (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, e.g. skilled nursing facilities or virtually

• Completes assessment of service needs per CMT and member's family/caregivers request to determine service needs or 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 agree with enrollment in a managed long-term care plan

• Fulfills all scheduling activities to ensure prospects/ members/ caregivers are scheduled and are aware of the scheduled visits

• Be able to fully participate in orientation, training and meeting activities as the role requires

• Additional duties as assigned

Minimum Qualifications:

• New York State RN license

• At least 1 year of prior UAS Assessment Nurse experience

• Ability to travel within the Bronx

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

• Unexpired NY state drivers license or NYS ID

• 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 agree

• 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.