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Nurse Care Manager-Hcba (1081)

Expired Job

Institute On Aging San Francisco , CA 94118

Posted 4 months ago

You may think "old" when you think of Institute on Aging (IOA) because we offer services for seniors and are a 40+ year institute. but you wouldn't be more wrong. While we do have a long-standing history in California, IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the "status-quo" and create new and more innovative ways to help aging adults maintain their quality of life. With over 23 programs, we offer multiple ways to aid seniors and adults with disabilities maintain their health, well-being, independence and participation in the community, fulfilling our mission.

The HCBA Waiver provides care management services to persons at risk for nursing home or institutional placement. The care management services are provided by a multidisciplinary care team comprised of a nurse and social worker. The care management team coordinates Waiver and State Plan services (e.g., medical, behavioral health, In-Home Supportive Services, etc.), and arranges for other available long-term services and supports available in the local community. Care management and Waiver services are provided in the Participant's community-based residence.

IOA is seeking a Nurse Care Manager for the HCBA Waiver Program. The Nurse Care Manager, who reports to the MSSP Program Director, is responsible for the following:

  • Conduct comprehensive nursing health assessments of participants' medical needs, diagnosis, functional and cognitive abilities, and environmental and social needs, to determine which service(s) are required to meet participants' needs and preferences in the community.

  • Document assessment, case notes, care coordination, and utilization management within the Med Compass system; a population health management software.

  • Work with the participants, their legal representatives, circles of support, and primary care physicians to develop goals associated with the participant's assessed needs, individual circumstances, and preferences.

  • Work with the participants, their legal representatives, and circles of support, and primary care physicians to develop a Plan of Treatment (POT) to mitigate risk and minimize disruptions in services.

  • Work with the participants, their legal representatives, and circles of support to identify when services identified in the POT are available through friends, family, and/or publicly funded programs.

  • Work with the participants, their legal representatives, circles of support, to implement the POT, which includes identifying service providers and community resources to help assure the timely, effective, and efficient mobilization and allocation of the services.

  • Work with the participants, their legal representatives, and circles of support to identify (and train, if necessary), backup caregivers who are willing and able to provide unpaid support if and when waiver service providers do not arrive when scheduled.

  • Provide information, education, counseling, and advocacy to, and on behalf of, participants.

  • Establish a care coordination schedule based on the needs and acuity of the participant as determined by their initial service needs assessment and subsequent reassessments.

  • Monitor the delivery of HCBA Waiver services to ensure participants are receiving services as authorized in their POTs.

  • Monitor the quality of the authorized services by maintaining ongoing contact with participants (including a monthly face-to-face visit or telephone call) to monitor for changes in health, mood, social integration, functionality, and overall well-being.

  • Conduct annual face-to-face visits, reassessments, and care plan updates; and, following up with the participant after Emergency Department and inpatient facility admissions.

  • All other duties as reasonably assigned.

REQUIRED QUALIFICATIONS:

  • Current, unencumbered license to practice as an RN in the State of California.

  • Current Basic Life Support (BLS) certification.

  • A minimum of 1000 hours of experience in the previous two years, in an acute care hospital caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver.

OR

  • A minimum of 2000 hours of experience in the previous three years, in an acute care hospital caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver.

  • A minimum of 2000 hours of experience in the previous five years, working for a licensed and certified home health agency caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver.

  • A minimum of 2000 hours of experience in the previous five years in an area not listed above, that in the opinion of DHCS, would demonstrate appropriate knowledge, skill and ability in caring for individuals at one or more of the levels of care specified in this waiver.

  • Experience establishing short and long-range goals for patient care which contribute to a continuum of care focus, and patient care will be delivered in accordance with the professional nursing process, which resulted in the delivery of quality patient care.

  • Experience with and understanding the medical diagnoses and medication associated with functionally impaired adults and older adults.

  • Experience working with individuals with mental and/or behavioral health diagnoses and substance abuse disorders highly desired.

  • Exceptional communication and presentation skills relating to functionally impaired adults and older adults, their support systems and teams of health professionals.

  • Demonstrates case management skills and experience in the community health care delivery system.

  • Detail oriented with good problem-solving skills and the ability to prioritize multiple tasks.

  • Computer literacy required.

The mission that drives us: IOA wants everyone to AgeOn!

Institute on Aging works to enhance the quality of life for adults as they age by enabling them to maintain their health, well-being, independence and participation in the community.

Who we serve:

We serve a diverse population of older adults and disabled adults without regard to ethnicity, religion, sexual identity, or social status. We embrace the Bay area's vibrant and varied culture, celebrating the diversity of its inhabitants. We have a commitment to representing, honoring, and enhancing the journeys of all aging adults, including those from different cultural backgrounds as well as seniors within the LGBT community.

We continuously seek to embrace and uphold our values:

Integrity, Authenticity, Collaboration, Innovation, Accountability and Compassion.

A little about our benefits:

A fit for all, our benefits will have you covered whether you are single, married, or in a domestic partnership, including kids or no kids! We offer two healthcare plans to choose from, provide 9 paid holidays, one floating holiday, and two weeks paid vacation (three weeks after your 1-year anniversary hits). Additionally, we have paid parental leave, family medical leave, 403(b) plans, pre-tax commuter benefits and other options. We foster an open work environment that supports and promotes diversity, inclusion and individuality. Employee Resource Groups and wellness programs are also available.

We encourage you to learn more about IOA by logging onto www.ioaging.org/about-ioa

IOA is an Equal Opportunity Employer: minority/female/disability/veteran

  • LI-MG1
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Nurse Care Manager-Hcba (1081)

Expired Job

Institute On Aging