Duties and Responsibilities:

Conducts 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 facilities

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

Additional duties as assigned

Minimum Qualifications:

New York State RN license.

Ability to travel to Bronx NY.

Preferred Qualifications:

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 are in agreement

Time management, critical/creative thinking, communication, and problem-solving skills

Field experience assessing, planning, and evaluating member's/patients care

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.