SCO RNCM Danvers/Peabody/Marblehead

2 weeks ago

ManchesterbytheSea, Massachusetts, United States Infojini Full time
Ability to travel frequently to member's homes, hospitals, skilled nursing facilities, PCP office practices and other sites where patients receive care
Timely completion of initial and ongoing geriatric assessments
Development and communication (with member, caregiver and primary care physician/primary care team) of an individualized plan of care
Completion of the Minimum Data Set-Home Care (MDS-HC)

Facilitation of member and caregiver access to community resources relevant to the member's needs, including referrals to Adult Day Health, Adult Foster Care and the Personal Care Attendant Program.

Participation in routine primary care team meetings
Pro-active management and follow-up (via home visits and by telephone) according to the member's care plan
Management and coordination of all transitions of care, including:
Communicating care plan to providers in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care) and ensuring providers receive timely clinical data that may impact healthcare treatment decisions
Direct caregiver support
Serves as a member advocate and facilitator to resolve issues that may be barriers to care
Provide education and coaching to the member, family, and/or caregiver about health status, treatment options, goals of care, and health insurance benefits to assist members in making the most informed decisions and help promote self-management
Work cooperatively as a team member across multiple levels within the organization
Demonstrate initiative in achieving individual, team, and organizational goals and objectives
Must be able to prioritize work and develop strategies for adapting to constantly changing priorities and urgent needs.
Regard for confidential data and adherence to corporate compliance policy
Demonstrate cultural competency and sensitivity
Demonstrate the ability to work autonomously

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