Senior Care Options Transition RN

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Requirements:

• Registered Nurse with current unrestricted license in state of residence
• Experience in home care or case management preferred
• Proficiency in second language desirable
• Experience in specialty areas such as oncology, neurology, chronic condition/disease management a plus

Responsibilities:

• Administer assessments, collaborate with the member/caregiver and providers to develop a plan of care, implement member-specific CM interventions, and evaluate plan of care and revise as needed.
• Facilitate program enrollment utilizing key motivational interviewing skills
• Provide targeted health education, proactive strategies for condition management, and communication with key providers and vendors actively involved in the member’s care
• Perform both telephonic and face to face outreach to assess barriers to wellness, medical, behavioral, and psychosocial needs of the member.
• Collaborate with member/caregiver and the facility care team to coordinate a safe transition to the next level of care, which includes but is not limited to ensure understanding post-hospital discharge instructions, facilitate needed services and follow-up, and implement strategies to prevent re-admission
• Performs case documentation in applicable CM system according to department and regulatory standards
• Collaborates and liaises with the interdisciplinary care team, to improve member outcomes (i.e., Utilization Management, Medical Director, pharmacy, community health workers, dementia care specialists, wellness, and BH CM)
• Attend and  present (as appropriate), high risk members at interdisciplinary rounds forum
• Maintain professional growth and development through self-directed learning activities
• Other duties and projects as assigned.