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 facilities

• Complete assessments of service needs per Care Management Team and member's family/caregivers request to determine service needsor any necessary adjustments

• Review previous nursing assessments/medical notes to determine necessary adjustments/updates in Care Plan and/or to assist with nursing home admission

• Conduct in-person Care Management visits in support of person-centered service planning

• Liaison between the member and the CMT; assesses home environment and psychosocial status

• Provide feedback to home care agencies and CMT regarding home care issues and contract nurses and aides performance

• Provide grass roots, community-based training for frail population care including self-care techniques and prevention strategies

• Ensure (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 in and around Bronx, New York

• Unexpired NY state drivers license or NYS DMV ID

Preferred Qualifications:

• Geriatrics

• Home Care

• Discharge Planning

• Case Management

• Medical Surgical Nursing

• Electronic patient health information (PHI) database experience

• 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

• 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.