Assessment Nurse Case Manager - Hybrid - Plymouth
About The Position
The Assessment Nurse Case Manager completes face-to-face home visits for new enrollees within 30 days of enrollment to onboard them and complete regulatory assessments. The role completes in-person Health Risk Assessments (HRAs) at the frequency assigned to each member, all new Personal Care Attendant (PCA) assessments using the integrated time-for-task tool, and yearly PCA reevaluations. The nurse is responsible for timely and accurate submission of yearly MDS assessments and assessments when there is a significant change in a member’s status. Assessments are primarily conducted in person, but may sometimes be completed by telephone or virtually. The position also provides education about the NaviCare case management program, collaborates with the Care Team, and completes LTSS evaluations in collaboration with Utilization Management.
Requirements
- Graduate from an accredited school of nursing.
- Active, unrestricted Registered Nurse license in Massachusetts.
- At least 1 year of clinical RN experience with complex medical, behavioral, and social comorbidities.
- Ability to conduct in-person and telehealth assessments.
- Ability to work on interdisciplinary teams.
- Skill in screening social determinants of health.
- Strong communication and interviewing skills.
- Problem-solving skills and adaptability.
- Knowledge of regulatory requirements or willingness to learn them.
- Valid driver's license and attestation to having no disqualifiers under the Driver Safety Policy.
- Proof of at least the minimum state-required auto insurance.
- Reliable transportation.
- Driving a personal motor vehicle is an essential job function.
Nice To Haves
- Bachelor’s or advanced degree in nursing or a health care-related field.
- Certification in Case Management.
- Experience in Home Health, OASIS/MDS, Medicare/Medicaid, or face-to-face member interactions.
- Reliable home internet.
Responsibilities
- Conduct home visits for onboarding and regulatory assessments.
- Complete Health Risk Assessments and Personal Care Attendant assessments and yearly reevaluations.
- Submit timely and accurate yearly MDS assessments and assessments following significant changes in member status.
- Provide education about the NaviCare case management program.
- Conduct telephonic or virtual assessments when appropriate.
- Collaborate with the Care Team.
- Complete LTSS evaluations and collaborate with Utilization Management.
- Conduct in-home assessments using motivational and culturally sensitive interviewing.
- Perform medication reconciliation.
- Complete state-required assessment tools in accordance with contract requirements.
- Conduct functional assessments for LTSS programs.
- Participate in training and audits.
- Maintain knowledge of programs and policies to educate members.
- Support HEDIS, Medicare 5 Star, and other initiatives.
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What This Job Offers
Job Type
Full-time
Education Level
Associate degree
