Nurse Case Manager - Primecare

GENERAL OVERVIEW:

The PRIMECARE Nurse Care Manager is a member of a department providing fee-for-service geriatric care management services to elders and those who care for them.

The role is varied, complex and highly visible, thus requires sufficient experience in elder care management to practice independently. The ability to establish effective collaborative relationships with a broad spectrum of people is essential. Work schedule is flexible to meet the needs of clients and clinical practice operations. Independent travel to elder's location is necessary.

The objective of the position is to provide contracted professional care management services to the elder and/or the elder's "representative". These services will enable, enhance and support the elder and/or their representative in the selection, provision and management of appropriate, quality, cost-effective goods and services in the least restrictive of settings.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

The Nurse Care Manager's primary responsibility is to the elder.

Specific care manager professional service responsibilities will be to:

1.Perform comprehensive and targeted geriatric care management and "informal" caregiver assessments in a variety of settings.

2.Analyze assessment issues and findings, research good quality, cost effective strategies and solutions.

3.Develop a comprehensive written geriatric care management "action plan" based upon the elder's safety, well being, goals and with consideration of the caregiver's needs and goals.

4.Provide concrete methodologies and recommendations for successful implementation of the action plan.

5.Provide "action plan" implementation services which may include:

care coordination to support delivery of medical, psychosocial care and associated care plans, activities of daily living, legal, financial management, etc.

education regarding the health care delivery and reimbursement systems, prescription drug cost management, health & wellness programs, long term care insurance, health care proxy, asset and legal management, government, community agencies, public & private organizations, hiring through private entities, etc.

advocacy, to include writing appeals, to ensure the elder's safety, physical, legal & financial well-being, to support their caregiving & quality of life goals, navigate the healthcare delivery system, obtain third party reimbursement for covered goods and services, etc.

assessment and monitoring of care being delivered to the elder and provision of recommendations to the elder and/or their representative regarding the advisability of the need to modify care, the care plan, providers and/or vendors, as necessary and appropriate consultation and/or conferencing with the elder & their formal, informal caregivers, family, significant others, representatives to assess issues, consolidate information, coordinate planning and care delivery with and for the elder

assistance with selection and transitioning the elder from one environment to another

6.Communication with the elder, their representative and/or providers to effectively implement plans and provide updates regarding ongoing eldercare care management issues and services.

7.Practice and documentation of care management services per PRIMECARE professional standards of practice.

8.Effective management of professional service billing.

Patient Population Served:

The staff member must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served on his/her assigned unit.

Senior Adult (55 to 64 yrs)

Geriatric (65 yrs and up)

• Strong assessment and problem solving skills.

• Strong interpersonal skills.

• Ability to work independently with minimal supervision.

• Goal oriented and accountable.

• Demonstrated organizational and time management skills, including ability to flex schedule to meet client & business need.

• Strong oral and written communication skills.

• Interest and ability in small business operation and development

Local Travel Required

• Registered Nurse with BSN and current MA license

• Minimum of 5 years work experience, 2 of which must be related

• Current Massachusetts Driver's License and ability to travel to client location/s

• CMC or CCM Certification preferred