Description

Revision Date: Wednesday, September 7th, 2022

Primary Function:

The Senior Care Options (SCO) RN Case Manager provides direct services to adults age 65 and older and consultation to staff and families in accordance with health center policies and professional standards. Responsibilities are focused on providing individualized clinical case management services to SCO patients. (Including: comprehensive assessment/MDS assessments, referrals to necessary services, ongoing support, follow-up and coordination with primary care provider and specialists). Responsible for the evaluation of patients as well as providing monitoring and follow-up. Execute physician orders as required and be professionally responsible to nurse practitioners, medical director and operations’ manager.

Duties & Responsibilities:
1. Provide primary clinical case management for patients through collaboration with SCO team (enrollment coordinator, physician, GSSC and nurse practitioner/physician assistant).
2. Delivers patient care/patient education in appropriate manner according to age, physical ability, educational level and culture.
3. Conduct health assessments and evaluate the needs of patients in the primary care clinic and in the home setting
4. Conduct physical exams, order and/or perform laboratory and diagnostic tests, and make clinical judgments regarding results. The SCO nurse practitioner/physician assistant or the primary care provider will provide clinical back-up as needed.
5. Conducts a variety of assessments including but not limited to MDS and LTSS assessments
6. Provides culturally appropriate care coordination, demonstrates culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives
7. Supports department colleagues, covering and assuming changes in assignment as assigned by Supervisor/designee
8. Participate in trainings provided by CCA
9. Follow CCA/UCHC documentation requirements
10. Comply with CCA/UCHC guidelines and changing regulations as needed
11. Participate in development of comprehensive patient plan of care.
12. PCA assessments
13. Initiate appropriate consultation and referrals.
14. Utilization Management
15. DME orders/coordination and management
16. Assistance with Prior Authorizations management and fulfillment
17. Provide health information and teaching with emphasis on prevention and curative treatment.
18. Act as primary care resource to the Multidisciplinary Team, and provide in-services for staff.
19. Participate in teaching activities with nurses, nurse practitioner, and medical students.
20. Document history & physical, assessment and treatment intervention in record.
21. MDS completion
22. Participate in committees for quality of care, standards of care, policies and procedures, and other program development activities.
23. Maintain patient confidentiality at all times
24. Maintain current standards of practice and seek professional development.
25. Participate in regularly scheduled clinical care, team and department meetings.
26. Develop and modify, when necessary, an individual care plan for each client based on the assessment above that identifies the needs of the client, and includes short and long term goals, objectives, specific services, providers giving care, time frames to reach each objective, and who will address unmet needs.
27. Make home visits as necessary to ensure that the services needed of the homebound enrolled are met.
28. Perform other duties as required.

Qualifications

Minimum Basic Knowledge:

Licensed Registered Nurse (B.S.N. preferred) in Massachusetts

Experience & Qualifications:

-Two years of nursing experience in community health setting
-Experience in culturally diverse setting
-Bilingual in Vietnamese or Spanish, Portuguese Creole is preferred.

Independent Action:

Ability to work independently and seek supervision when necessary.

Supervisory Responsibility:

There are no supervisory responsibilities.

Define Access Level to PHI:

4 [Authorized to access full health information. UCHC position and job responsibilities involve the provision of patient care and working as a clinical team member. Staff in this category level, although allowed full access, should only access the necessary information for each respective treatment encounter/circumstance.]