LTSS Assessment RN (SCAN Temp)

SCAN Health Plan•Los Angeles, CA

4d•Remote

About The Position

The LTSS Assessment RN enhances frail seniors’ ability to age in place, manage their health, navigate the health care system, and live independently. The role provides person-centered care through SCAN’s care management, disease management, complex care management, and enhanced care management programs. The nurse works directly with members by telephone to develop and implement plans of care, provide health education and coaching for chronic conditions, and help prevent symptom exacerbations, avoidable emergency room visits, and hospital admissions. The RN performs initial and annual telephonic assessments with a Community Health Worker for Medi-Cal/Medicare dually eligible members referred to Care Coordination for Long-Term Services and Supports (LTSS), including determining Nursing Facility Level of Care. The role evaluates assessment findings against evidence-based guidelines, clinical reasoning, best practices, and community standards to support clinically appropriate, member-centered care plans. The nurse may also participate in interdisciplinary planning and case conferences, particularly to support members following discharge from an inpatient or institutional setting, and builds working relationships with Medical Groups teams. The position includes providing education, coaching, and disease management as needed; promoting member engagement and self-management; and completing timely, accurate documentation across multiple computer systems, including assessments, care plans, service plans, authorizations, and progress notes. The RN adheres to SNP Model of Care requirements and applicable quality, compliance, and regulatory standards, including those of CMS, DHC, and DHCS. The role supports SCAN’s vision and goals and may include other duties as assigned. This is a temporary, telephonic remote position working Pacific time zone business hours. A California RN license is required.

Requirements

Associate’s degree in nursing (ASN).
California Registered Nurse (RN) license.
At least 3 years of experience in managed care, a healthcare environment, or case management.
Strong interpersonal skills, including excellent written and verbal communication.
Strong organizational, critical-thinking, decision-making, and multitasking skills.
Ability to appropriately maintain confidentiality.
General understanding of NCQA standards and CMS and DHCS regulations.
General knowledge of medical terminology and abbreviations.
Deep understanding of local community resources for seniors.

Nice To Haves

Bachelor’s degree in nursing (BSN); strongly preferred.
Graduate or advanced degree.
Bilingual English/Spanish proficiency; testing may be administered.
At least 2 years of experience working with seniors and working remotely; strongly preferred.
Leadership skills, including developing others.
Problem-solving skills, including making critical decisions involving high-level risk assessment and adapting to changing circumstances.
Strategic mindset, including formulating strategies and mapping steps to achieve strategic goals.
Curiosity about AI and its potential to transform operations and member service.

Responsibilities

Perform initial and annual telephonic assessments with a Community Health Worker for Medi-Cal/Medicare dually eligible members referred to LTSS Care Coordination, including determining Nursing Facility Level of Care.
Evaluate assessment findings using evidence-based guidelines, clinical reasoning, best practices, and community standards to ensure clinically appropriate, member-centered care plans.
Develop and implement plans of care and provide health education and coaching to support chronic condition management and prevent symptom exacerbations, avoidable emergency room visits, and hospital admissions.
Integrate clinical insights and community standards into comprehensive care strategies.
Participate as needed in interdisciplinary planning and case conference meetings, including supporting members after discharge from inpatient or institutional settings.
Build strong working relationships with Medical Groups teams.
Provide education, coaching, and disease management for chronic conditions as needed, identifying preventive interventions to avoid exacerbations or worsening conditions.
Promote member engagement, patient activation, and self-management to support successful health outcomes.
Complete timely and accurate documentation in multiple computer systems, including assessments, care plans, service plans, authorizations, and progress notes.
Adhere to SNP Model of Care requirements and procedures, and applicable quality, compliance, and regulatory standards, including CMS, DHC, and DHCS requirements.
Support the achievement of SCAN’s vision and goals and perform other duties as assigned.