Nurse Care Manager, HCBA
Employment Type: Full-Time
You may think 'old' when you think of Institute on Aging because we offer services for elders and are a 40+ year institute…. but you wouldn't be more wrong. While we do have a long-standing history in the Bay Area, IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the 'status-quo' and create new and more innovative ways to help aging adults maintain their quality of life. With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence, and participation in the community, fulfilling our mission.
The Home Community Base Alternatives Waiver (HCBA) provides care management services to persons at risk for nursing home or institutional placement. The care management services are provided by a multidisciplinary care team comprised of a nurse and social worker. The care management team coordinates Waiver and State Plan services (e.g., medical, behavioral health, In-Home Supportive Services, etc.), and arranges for other available long-term services and supports available in the local community. Care management and Waiver services are provided in the Participant's community-based residence.
The (HCBA) Department is seeking a Nurse Care Manager (Per-Diem), to join its team for the San Francisco/ San Mateo region. This position is currently remote and will later return to the community.
* Conduct comprehensive nursing health assessments of participants' medical needs, diagnosis, functional and cognitive abilities, and environmental and social needs, to determine which service(s) are required to meet participants' needs and preferences in the community.
* Document assessment, case notes, care coordination, and utilization management within the Med Compass system; a population health management software.
* Work with the participants, their legal representatives, circles of support, and primary care physicians to develop goals associated with the participant's assessed needs, individual circumstances, and preferences.
* Work with the participants, their legal representatives, and circles of support, and primary care physicians to develop a Plan of Treatment (POT) to mitigate risk and minimize disruptions in services.
* Work with the participants, their legal representatives, and circles of support to identify when services identified in the POT are available through friends, family, and/or publicly funded programs.
* Work with the participants, their legal representatives, circles of support, to implement the POT, which includes identifying service providers and community resources to help assure the timely, effective, and efficient mobilization and allocation of the services.
* Work with the participants, their legal representatives, and circles of support to identify (and train, if necessary), backup caregivers who are willing and able to provide unpaid support if and when waiver service providers do not arrive when scheduled.
* Provide information, education, counseling, and advocacy to, and on behalf of, participants.
* Establish a care coordination schedule based on the needs and acuity of the participant as determined by their initial service needs assessment and subsequent reassessments.
* Monitor the delivery of HCBA Waiver services to ensure participants are receiving services as authorized in their POTs.
* Monitor the quality of the authorized services by maintaining ongoing contact with participants (including a monthly face-to-face visit or telephone call) to monitor for changes in health, mood, social integration, functionality, and overall well-being.
* Conduct annual face-to-face visits, reassessments, and care plan updates; and, following up with the participant after Emergency Department and inpatient facility admissions.
* All other duties as reasonably assigned.
* EDUCATION: Required Current, unencumbered license to practice as an RN in the State of California.
* Required: Ability to pass Criminal background Check & Live Scan.
* Required: Current Basic Life Support (BLS) certification.
* A minimum of 1000 hours of experience in the previous two years, in an acute care hospital caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver.
* A minimum of 2000 hours of experience in the previous three years, in an acute care hospital caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver.
* A minimum of 2000 hours of experience in the previous five years, working for a licensed and certified home health agency caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver.
* A minimum of 2000 hours of experience in the previous five years in an area not listed above, that in the opinion of DHCS, would demonstrate appropriate knowledge, skill and ability in caring for individuals at one or more of the levels of care specified in this waiver.
* Experience establishing short and long-range goals for patient care which contribute to a continuum of care focus, and patient care will be delivered in accordance with the professional nursing process, which resulted in the delivery of quality patient care.
* Experience with and understanding the medical diagnoses and medication associated with functionally impaired adults and older adults.
* Experience working with individuals with mental and/or behavioral health diagnoses and substance abuse disorders highly desired.
* Exceptional communication and presentation skills relating to functionally impaired adults and older adults, their support systems and teams of health professionals.
* Demonstrates case management skills and experience in the community health care delivery system.
* Detail oriented with good problem-solving skills and the ability to prioritize multiple tasks.
* Computer literacy required.
We encourage you to learn more about IOA by logging onto www.ioaging.org
IOA reserves the right to revise job descriptions or work hours as required
Institute on Aging is an Equal Opportunity Employer. Institute on Aging is committed to cultivating a diverse and inclusive work environment and providing equal opportunities to all employees and job applicants without regard to age, race, religion, color, national origin, sex, sexual orientation, gender identity, genetic disposition, neuro-diversity, disability, veteran status or any other protected category under federal, state and local law.