Nurse Assessor​/Field Nurse

What is today the Isabella Geriatric Center was founded over 100 years ago out of a young woman’s compassion for those in need. Isabella Uhl dreamed of creating a home for aged women who had no homes or families. Before her untimely death at age 27 of an incurable illness she asked her parents to fulfill that dream for her and on May 15 1875 Isabella Home opened its doors to 25 aged indigent women.

Since that time as the need for services became greater and more complex we embarked on a visionary program of expansion that also broadened Isabella’s scope and its mission. In addition to adding skilled nursing beds we looked beyond traditional nursing home walls to develop programs that met the changing needs of older adults in a rapidly changing society.

This position has 2 components:

• Completion of a Uniform Assessment (UAS) of the Managed Long Term Member’s clinical, cognitive, functional, psychological and social needs. Based on the assessment the Nurse Assessor completes a comprehensive plan of care that is communicated to the member, PCP, PCW vendor, and the Care Management team. All documentation and clinical information is communicated on a timely basis to the Care Management team for in‑office care coordination and additional care plan development.
  
  All requests for service assigned to the Nurse Assessors are evaluated and recommendations are communicated to the Care Management team.
• Evaluates, directs and supervises home care workers (PCA/HHA) providing in‑home care services using LHCSA protocols.

Essential Functions and Responsibilities under Care Management:

• Conducts and completes Uniform Assessments (UAS) in the member’s home within DOH regulatory time frames and MLTC plan’s protocols. Nursing Home UAS visits are made as required.
• Completes all urgent requests for service. Communicates safety issues, changes in condition, or clinical care needs to the PCP and Care Management team upon completion of assessment on same day of identification.
• Assesses member in the home to evaluate for requests for service.
• Utilizes Medicare, Medicaid, and internally developed criteria to assess member’s eligibility for requested service.
• Submits recommendation and supporting documentation to the Care Management team within 1 business day of completed assessment, keeping within regulatory and unit time frames.
• All urgent issues are communicated verbally and or via email to the appropriate care management team with cc to supervisor.
• Obtains orders from the PCP as needed (including skilled home care) and communicates information to the care management team.
• Creates/updates an individualized, comprehensive plan of care for the member, based on assessment.
• Validates initial plans of care and communicates changes as appropriate to the Care Management team.
• Completes all required documentation which addresses clinical, social, psychological, and preventive health needs of the member that are identified through the assessment/re‑visit process and communicated with member’s PCP.
• PCW Plan of care is created or updated during assessment/re‑visit, and reviewed with the member, member’s representative and PCW. Comprehensive Plan of care is communicated to the member’s PCP and vendor as per plan’s protocols.
• Communicates and submits all completed assessments and completes and submits all required documentation within 3 business days of visit. Corrections to notes will be submitted within 1 business day.
• Communicates inability to make assessment visits i.e. out of area, hospitalized, and refused to the care management team for follow‑up in a timely manner.
• Participates in inter‑disciplinary team meetings, educational programs and other meetings as needed.

Essential Functions and Responsibilities under IVCI‑LHCSA:

• Evaluates, directs and supervises home care workers including Personal Care Workers and Home Health Aides under LHCSA protocols and standards.
• Participates in the remediation or discipline of aides based upon performance and/or failure to meet standards of services/care set by the agency.
• Develops a Paraprofessional Plan of Care for those individuals who require home care services based on the home care…