Home Care Manager, RN (Full-Time)

Hudson Headwaters Health Network•City of Glens Falls, NY

5d•Onsite

About The Position

The Program of All-Inclusive Care for the Elderly (PACE) is a community-based program that provides coordinated medical and social services to eligible older adults who want to continue living in their own home despite chronic care needs. The Home Care Manager, under direct oversight of the Director of Operations, is an integral member of the PACE at Hudson Headwaters (PHH) Interdisciplinary Team (IDT). The Home Care Manager is responsible for completing home care assessments for PACE participants as part of the PACE IDT care planning process which includes assessing participants for skilled and unskilled home care needs and durable medical equipment and other assistive devices. The Home Care Manager coordinates and supervises all participant home care interventions and assists the IDT in assessing PACE participants to determine their ability to be safely maintained in a community setting through PACE services.

Requirements

Bachelor’s RN degree is required.
Current New York State RN License.
Either have one year of experience working with a frail or elderly population or, in the absence of such experience, receive appropriate training from PACE on working with a frail or elderly population prior to providing participant care.
BLS certified or willing to complete necessary certification.
Trained, or willing to get trained, on how to complete PRI (Patient Review Instrument) and UAS-NY (Uniform Assessment System) assessments.
Demonstrate proficiency on a standardized set of core competencies for the PACE Home Care Manager position.
2+ years of supervisory health care experience, preferably in clinic with Home Care knowledge.
Must possess a valid driver’s license.
Ability to work within a clinical team with initiative, imagination, resourcefulness, and flexibility.
Experience and excitement to work with a diverse population of colleagues and participants.
Excellent interpersonal, verbal, and written communication skills.
Excellent time-management skills and ability to prioritize deadlines, delegate, and make decisions.
Knowledge and understanding of team-based care.
Must thrive in team environment and possess excellent organizational and supervisory skills and be able to effectively handle difficult interpersonal situations.
Demonstrated ability to carry projects through to completion in a timely manner.
Proficient computer competencies including Microsoft applications, including the ability to navigate Electronic Health Record platforms.
Must be able to work independently as well as collaborate and communicate effectively with colleagues, supervisors, service delivery partners, other health care professionals and co-workers to build and maintain effective dynamic professional team relationships.
Before engaging in participant care, be medically cleared for communicable diseases and have up-to-date immunizations and vaccines.
Have not been convicted of criminal offenses involving Medicaid, Medicare, other health insurance or health care programs, or social services programs under title XX of the Act.
Have not been excluded from participating in Medicare and Medicaid programs.
Have not been convicted of criminal offenses pertaining to physical, sexual, drug, or alcohol abuse.

Responsibilities

In collaboration with the IDT, develop and implement home care plans for participants, identifying and considering the medical, physical, social, and emotional needs of PACE participants.
Utilizing PACE home care staff and home care contracted providers, schedule and monitor in-home care delivery consistent with individual participant care plans.
Proactively and continuously communicate with PACE home care staff and home care contracted providers and relay participant status changes to IDT members promptly.
Conduct participant assessments using assessments such as the UAS-NY (Uniform Assessment System) and PRI (Patient Review Instrument).
Along with the IDT, work with acute and sub-acute discharge planners to coordinate safe discharge back home or to alternate placement with necessary home health care and DME with the goal of minimizing hospital lengths of stay as appropriate.
Audit and coordinate with home care agencies on contracted staff to ensure all regulatory trainings, certifications and health assessments have been completed and are up to date.
Work with contracted providers, participants, and families for coordination of appointments and services.
Assist with providing nursing/clinical orientation, completing competency assessments when required, and provide necessary training to clinical staff.
Work with the Clinical Leader, Medical Director, and Director of Operations to control and prioritize utilization of home care staffing resources to reflect actual participant home care needs.
Monitor home care documentation to ensure care coordination and comprehensive medical record documentation is being completed.
Support the PACE QI program and participate in PACE QI activities as assigned.
Provide professional mentoring and monitoring of all home care nursing staff.
Collaborate with therapy staff to obtain and track equipment, supplies and services used in the home such as durable medical equipment and incontinence supplies as reflected in the care plan.
Effectively communicate with participants and their families regarding home care needs, grievances, and other concerns.
Ensure that work areas are maintained in a clean, sanitary, and safe manner to meet NYS/Federal regulations and PHH policy and procedures.
Provide educational in-services to staff as necessary.
Participate in the administrative on-call rotation to provide after-hours and weekend call coverage to PACE participants.