Job Description

The Per Diem RN assessment nurse conducts the (UAS) NYS community health assessments in the member’s home or virtually. This will also include 6-month face-to-face visits.

1. Conducts face to face assessment of members utilizing required NYS UAS Assessment Tools, and/or other tools as directed by NYS or other regulatory bodies, to determine functional status, medical, behavioral, psychological, and community resource needs, as well as member’s level of work capacity and related restrictions/limitations .
2. Adheres to all Corporate and Departmental policies and ensures all regulatory requirements such as DOH, CMS, Medicaid, and accreditation requirements such as NCQA, URAC and HEDIS functionalities are met or exceeded. Accesses Health Commerce System (HCS) and complete/maintain all mandatory trainings as required.
3. Concise documentation in the community health assessment that adheres to Elderwood IPA’s documentation standards.
4. Compare re-assessment data to baseline assessment to monitor Members’ progress, recognize alterations in function, including life-threatening situations, and intervene and document appropriately.
5. Closely communicate and collaborate with primary care practitioners, interdisciplinary team, and family members.
6. Ensure that documentation in the care management record meets all applicable professional standards, using an EMR for each observation, verbal report, or interaction with the Member, Member’s caregiver/family, PCP or other provider, whether by home visit, telephonic, or written interaction.
7. Provide coaching and education to Members and their caregivers on health care related issues such as advanced directives, disease, chronic condition, and medication management. Initiate patient education based on identified learning needs of the Member and/or those providing care.
8. Early identification of incipient problems or significant changes in Member conditions to initiate early intervention and strategies to prevent or more quickly treat chronic care exacerbations.
9. Recognizes and follows the dress code of the facility including wearing name tag at all times.
10. Follows policy and procedure regarding all electronic devices, computers, tablets, etc.
11. Supports and abides by Elderwood’s Mission, Vision, and Values.
12. Abides by Elderwood’s businesses code of conduct, compliance and HIPAA policies.

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