Senior State Home Care Community Health Nurse in Somerville, Massachusetts at Somerville-Cambridge Elder Services Incorporated

JOB DESCRIPTION

Job Title: Senior State Home Care Community Health Nurse

Reports To: State Home Care Nurse Manager

Department: Home Care

FLSA Status: Exempt or X Non Exempt

Union or X Non-Union

Position Summary:

The Senior State Home Care Community Health Nurse assesses and/or authorizes health services and serves as an integral member of the Home Care Department. They work closely with the Nurse Manager and Home Care Director and provides oversight and management of one or more specialized programs such as: Coordination of Care, Comprehensive Service and Screening Model, Choices and/or Enhanced Community Options Program. They participate in determining consumer eligibility for Home Care and Medicaid funded services based on nursing assessment data provided through direct consumer assessments in the community, hospital, or nursing home and oversee referrals and assignments for the Home Care nursing team. They provide periodic monitoring of consumer records and appropriateness and quality of care authorized, including overseeing all consumer cases in Home Care’s extended care program. The Senior State Home Care Community Health Nurse provides leadership and nursing team oversight in the Nurse Manager’s absence and acts as in-house consultant regarding the health issues of aging along with EOEA and Medicaid’s home and community-based waiver program requirements as it relates to the department’s nursing team. They maintain collaborative relationships among community agencies, healthcare providers, vendors, and nursing home staff.

Job Responsibilities and Performance Standards:

• Provide oversight and management of one or more specialized programs. Oversee all consumers in Home Care’s extended care program and ensure that all required paperwork and internal policies and procedures are adhered to by the vendors, consumer, family members, and case management staff.
• Provide clinical nursing supervisory coverage for the Nurse Manager.
• Monitor consumer health status for changes; conduct post-hospital and/or other reassessments to evaluate consumer’s health, safety, needs, and any other changes that may warrant adjustments to service plans and/or potential transfers into an enhanced Home Care program.
• Respond to, monitor, and assign referrals from case managers, families, and community agencies to members of the Home Care’s nursing team in a timely and complete manner. Does so in accordance with EOEA, state, federal, and Agency regulations and guidelines.
• Conduct in-person assessments in consumers’ homes, hospital, and/or nursing homes to determine Home Care program eligibility and ensure that the consumer’s plan of care and services are appropriate and meeting needs. Does so in accordance with EOEA, state, federal, and Agency regulations and guidelines.
• Develop and complete an individualized, goal-directed consumer care plan, considering health status and social structure and reassess and/or revise care plan as appropriate.
• Provide in-service training and informal and formal consultation regarding health issues to consumers, families, caregivers, Agency staff, and community providers.
• Advocate, network, and educate families, consumers, and community providers about SCES’ health service programs as needed.
• Maintain documentation for consumer records and completion of required paperwork in an accurate, complete, confidential and timely manner. Does so in accordance with EOEA, state, federal, and Agency regulations and guidelines.
• Participate in Core Team Meetings with the Nurse Manager and CSSM Case Manager to identify and review nursing facility residents for participation in the Comprehensive Service and Screening Model (CSSM). Identify consumers who may require the most immediate need for CSSM services and those who wish to return to the community from the nursing home.
• Meet with discharge planner(s) at their assigned nursing home on a weekly basis to review MassHealth members/applicants’ current stage of rehabilitation or recuperation.
• Conduct in-person clinical eligibility screenings based on a comprehensive health and functional and psychosocial assessment of MassHealth members/applicants seeking approval for MassHealth payment of nursing facility services.
• Participates in interdisciplinary case conferences on the consumer’s services, needs, recommendations for care, program eligibility, and care coordination.
• Participate in department quality improvement initiatives as needed. Provide data for preparation of monthly statistical reports and maintain records.
• Participates in EOEA, Agency, and Departmental meetings and trainings as required.
• Comply with HIPAA and other state and Agency confidentiality and documentation requirements.
• Performs other duties as assigned including translation/interpretation assistance as needed if bilingual.

Professional Standards and Conduct:

• Leadership: Ability to lead, inspire, and empower staff by demonstrating confidence and leadership presence. Passion and commitment to establishing and developing evidence-based programming for individuals to live in the setting of their choice with dignity and for as long as possible.
• Collaborative and Responsive: Regularly communicate, follow up, and use a team-driven approach. Respond thoughtfully and promptly to agency needs, requests, and inquiries; identify and build partnerships with key stakeholders. Demonstrates excellent organizational and time management skills to meet various deadlines, ensuring closed-loop communication. Ability to multi-task and maintain flexibility to adapt and adjust workload assignments based on various needs.
• Communication: Skilled in verbal and written communication, demonstrating the ability to communicate information in various ways to meet diverse styles and cultural backgrounds.
• Analytical: Critical thinking skills, using logic and reasoning to identify the strengths and opportunities of alternative solutions, conclusions, or approaches to problems.
• Attendance and Punctuality: Dependable, punctual, showing flexibility when needed. Attends meetings as needed and is fully present and participates during those meetings.
• Commitment: Embodies SCES’s core values and shows great integrity, accountability, and professionalism in all interactions. Aids in furthering SCES’s mission and commitment to an inclusive environment.

Qualifications:

• Graduation from a School of Nursing accredited by the National League for Nursing required, B.S.N. preferred.
• Valid license as a registered nurse in the Commonwealth of Massachusetts required.
• A minimum of three years of clinical experience required. One year of community health experience and/or Home Care program experience strongly preferred.
• Previous experience working with older adults strongly preferred. Previous Aging Services Access Point (ASAP) experience preferred.
• Must be able to work independently and collaboratively with health professionals, community agencies, service providers, and agency staff. Experience working within an interdisciplinary team preferred. Must be able to work with diverse populations.
• Ability to interpret and implement regulatory, contract, and business processes preferred. Must possess excellent problem solving and analytical skills.
• Exceptional time management and organizational proficiency. Should possess strong communication skills and the ability to multi-task in a fast-paced environment and ensure closed-loop communications.
• Must be knowledgeable and comfortable using Adobe and MS Word, Excel, SharePoint, and other Microsoft 365 platforms. Experience with Wellsky a plus.
• Must be accessible by phone, directly, or by coverage during normal business hours.
• Valid Massachusetts driver’s license strongly preferred. Must be able to travel to consumers’ homes and area hospitals and nursing homes via public transportation or by car.
• Must meet both CORI/SORI and public health screening requirements.
• Bilingual a plus.

Physical Environment

• Physical surroundings are comfortable with minimal exposure to injury or hazards.

Social/Psychological Conditions

• Occasional stress due to periodic or cyclical workload pressures and deadlines. Some interruptions involved.

Physical Effort

• Frequently sits, stands, walks, bends, reaches, and stoops throughout the day.
• Frequently lifts, pulls, pushes, and carries up to 20 lbs.
• Periodic eye strain and light ear strain.

Employee Name and Signature: ______________________________________ Date: ______________________

Supervisor Name and Signature: _____________________________________ Date: ______________________

Pay ranges from $85,000-105,000 depending on experience and skills.