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The Assessment Nurse makes field assessment visits for members or prospective members around downstate New York at intervals required by the Department of Health (DOH) and completes appropriate documentation to determine members’ enrollment, service needs, and continued plan eligibility. This position coordinates with Care Management Team (CMT) to maintain efficient and effective operations of Healthfirst’s long term care plans such as CompleteCare and Senior Health Partners. Strong technological proficiency is essential for this role as the Assessment Nurse must efficiently navigate multiple technology platforms throughout the course of their day.
Job Responsibility:
Conducts home assessments (and virtual assessments, as needed) 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
Navigates multiple technology/digital platforms such as UAS software, electronic medical records, TruCare, etc., to conduct and document comprehensive assessments accurately and efficiently
Completes assessment of service needs per CMT and member's family/caregiver’s request to determine service needs or any necessary adjustments
Reviews previous nursing assessments/medical notes to determine necessary adjustments/updates in Care Plan and/or to assist with nursing home admission
Conducts in-person Care Management visits in support of person-centered service planning
Liaisons between the member and the CMT
assesses home environment and psychosocial status
Provides feedback to home care agencies and CMT regarding home care issues and contract nurses and aides performance
Provides grass roots, community-based training for frail population care including self-care techniques and prevention strategies
Ensures (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
Requirements:
New York State RN license
Ability to travel around downstate New York which includes the 5 boroughs, Long Island, Rockland, and Westchester
Prior work experience requiring technological proficiency including the ability to navigate multiple technology platforms and modalities
Prior work experience requiring intermediate Microsoft Word, Excel, and Outlook skills
Prior work experience requiring time management, critical/creative thinking, communication, and problem-solving skills
For PEDS positions only: 1 year of pediatric clinical field experience and/or experience with families and child serving systems, including child welfare and/or medically fragile/developmentally disabled populations
Nice to have:
Work experience using electronic patient health information (PHI) database usage especially UAS
Previous field-based experience assessing, planning, and evaluating member's care by making home or facility visits for intake/reassessments or start of care (SOC) Community Home Health Agency (CHHA) visits
Work experience preferred in one or more of the following areas, geriatrics, home care, discharge planning, case management, and/or medical surgical nursing
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
Language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese