SCO RN Case Manager

Position Title:                     Senior Care Options (SCO) RN Case Manager
Department:                        Senior Care Options
Supervisor:                         SCO Clinical Coordinator
Status/Hours per week:     Non-exempt / 40 hours 
 

Primary Function:

The Senior Care Options (SCO) RN Case Manager provides direct services to adults age 65 and older and consultation to staff and families in accordance with health center policies and professional standards. Responsibilities are focused on providing individualized clinical case management services to SCO patients. (Including: comprehensive assessment/MDS assessments, referrals to necessary services, ongoing support, follow-up and coordination with primary care provider and specialists). Responsible for the evaluation of patients as well as providing monitoring and follow-up. Execute physician orders as required and be professionally responsible to nurse practitioners, Medical Director and Operations Manager.

Duties & Responsibilities:

• Provide primary clinical case management for patients through collaboration with SCO team (enrollment coordinator, physician, GSSC and nurse practitioner/physician assistant).
• Deliver patient care/patient education in appropriate manner according to age, physical ability, educational level and culture.
• Conduct health assessments and evaluate the needs of patients in the primary care clinic and in the home setting.
• Conduct physical exams, order and/or perform laboratory and diagnostic tests, and make clinical judgments regarding results (SCO nurse practitioner/physician assistant or primary care provider will provide clinical back-up as needed).
• Conduct a variety of assessments including but not limited to MDS and LTSS assessments. 
• Provide culturally appropriate care coordination, and demonstrate culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives.
• Support department colleagues, covering and assuming changes in assignment as assigned by supervisor/designee. 
• Participate in trainings provided by CCA.
• Follow CCA and UCC documentation requirements. 
• Comply with CCA and UCC guidelines, and changing regulations as needed. 
• Participate in development of comprehensive patient plan of care.
• Conduct PCA assessments.
• Initiate appropriate consultation and referrals.
• Use utilization management.
• Process durable medical equipment (DME) orders, as well as coordinate and manage DME. 
• Assist with Prior Authorizations management and fulfillment. 
• Provide health information and teach with emphasis on prevention and curative treatment.
• Act as primary care resource to the multidisciplinary team, and provide in-services for staff.
• Participate in teaching activities with nurses, nurse practitioner, and medical students.
• Document medical history, physical, any assessment, and treatment intervention in record.
• Handle Minimum Data Set (MDS) completion. 
• Participate in committees for quality of care, standards of care, policies and procedures, and other program development activities.
• Maintain patient confidentiality at all times.
• Maintain current standards of practice and seek professional development.
• Participate in regularly scheduled clinical care, team and department meetings.
• Develop and modify, when necessary, an individual care plan for each client based on the assessment above that identifies the needs of the client, and includes short and long term goals, objectives, specific services, providers giving care, time frames to reach each objective, and who will address unmet needs.
• Make home visits as necessary to ensure the services needed of the enrolled homebound patients are met.
• Perform other duties as required.

Minimum Basic Knowledge:

Licensed Registered Nurse (B.S.N. preferred) in Massachusetts

Experience & Qualifications:

• Two years of nursing experience in a community health setting ideal.
• Experience in a setting that serves patients with a variety of needs. 
• Bilingual language skills in Vietnamese, Spanish, or Portuguese Creole preferred.

Independent Action:

Ability to work independently and seek supervision when necessary or as required to carry out job duties listed above. 

Supervisory Responsibility:

None

Define Access Level to PHI:

Level 4 [Authorized to access full health information. UCHC position and job responsibilities involve the provision of patient care and working as a clinical team member. Staff in this category level, although allowed full access, should only access the necessary information for each respective treatment encounter/circumstance.]