Healthfirst

Duties and Responsibilities: 

• 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.  As needed, conducts assessments in settings other than home as needed, e.g. skilled nursing facilities or virtually

• 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

  Minimum Qualifications:

  • New York State RN license
  • Ability to travel around downstate New York which includes the 5 boroughs, Long Island, Rockland, and Westchester.
  • 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

    Preferred Qualifications: 

    • 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
    • Work experience using electronic patient health information (PHI) database usage especially UAS
    • NY state driver’s license
    • 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
    • Time management, critical//creative thinking, communication, and problem-solving skills
    • Language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese
    • Demonstrated ability handling heavy caseloads
    • Intermediate Microsoft Word, Excel, and Outlook skills