AERS and Nurse Monitoring Contractual) Community HEALTH NURSE II

The Community Health Nurse II performs assessments and nurse monitoring visits of elderly and/or disabled persons in their homes, hospitals, or institutions to determine community resources that are appropriate and available to meet the individual’s needs. This position also develops an individualized plan of care and serves as a health advocate and monitor for best living arrangement for the client.

This position has 2 vacancies.

19

8930 Stanford Boulevard
Columbia, MD 21045

The Community Health Nurse II performs assessments and nurse monitoring visits of elderly and/or disabled persons in their homes, hospitals, or institutions to determine community resources that are appropriate and available to meet the individual’s needs. This position also develops an individualized plan of care and serves as a health advocate and monitor for best living arrangement for the client.

Eligible for hybrid telework schedule.

• Works with professionals from other disciplines to plan and implement healthcare services in the community;
• Collaborates on special projects in the community to promote wellness;
• Monitors the Long
  -Term Services Support (LTSS) tracking system for alerts related to referrals, updates client information (LOC, change in status, reportable events, etc.), and assures information is accurate;
• Tracks referrals assigned;
• Manages an individual Assessment and Nurse Monitoring caseload to provide nursing care to individuals, families and the community;
• Ensures confidentiality of written, electronic and verbal communication;
• Uses appropriate lines of communication within and outside the agency;
• Responds to requests for information in a timely manner;
• Provides interpretation and translation services according to agency policy;
• Provides education appropriate to meet the needs of those with functional needs;
• Documents work accurately and within agency guidelines;
• Communicates with other agencies and other members of the health team regarding clients’ needs and condition(s);
• Accesses community resources to benefit client;
• Maintains sensitivity to the multi-cultural needs of the Health Department clientele and staff;
• Participates in ongoing continuous quality improvement initiatives through interdisciplinary conferencing and self-monitoring of record standards;
• Participates in MDH audits/conferences or other management requested QA activities;
• Attends state-wide AERS meetings as required;
• Attends in-service training, community and general staff meetings to maintain professional competency and for the purpose of improving service to recipients;
• Meets with clients, families/representatives and other required professionals to perform a comprehensive assessment of individuals utilizing the STEPS assessment tool (for PASRR only) or interRAI assessment tool;
• Works with appropriate parties to develop an inclusive plan of care by coordinating services with clients, family, other disciplines, health service providers, and agencies;
• Completes nurse monitoring visits and follow-up as needed, and works with providers to ensure appropriate care;
• Serves as a community resource on long-term care issues;
• Promotes wellness and disease prevention; adapts teaching to the educational level of the client, family, caregiver;
• Provides educational content that may include, but is not limited to, guidance regarding personal safety issues, nutrition, medications, problem solving and access to resources and agencies;
• Provides follow-up to clients through face-to-face, telephone contact and written correspondence;
• Provides evaluation information to office clerk for billing purposes.

• Monitors Nurse Monitoring visit due report to…