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MDS Registered Nurse
2 months ago
GENERAL OVERVIEW
This role is a vital component of the enrollment team, tasked with organizing, prioritizing, and customizing the PACE enrollment process to cater to the unique needs of potential participants, ensuring that enrollment targets are met. The position serves as a clinical intermediary among prospective participants, caregivers, the PACE enrollment team, the interdisciplinary team (IDT), and various community referral sources.
KEY RESPONSIBILITIES
Enrollment Team Duties
- Conduct initial consultations to explain the PACE model to potential participants and their caregivers.
- Verify that potential participants fulfill eligibility requirements as per PACE enrollment regulations.
- Employ a strengths-based approach to assess the current needs and health status of potential participants.
- Maintain proactive communication with the IDT regarding the enrollment status and progress of prospective participants.
- Balance and prioritize the needs of prospective participants and caregivers with the concerns of the IDT.
- Engage in weekly Enrollment Team meetings to offer clinical insights and support for challenging referrals and any arising conflicts.
- Ensure accurate data management of new referrals using CRM, EMR software, and relevant health gateways.
- Assist Marketing and Outreach in coordinating external events.
Nurse Coordinator Duties
- Conduct home visits for prospective participants to complete and submit the state-mandated Minimum Data Set- Home Care (MDS_HC).
- Perform comprehensive assessments, including evaluations of functional status, caregiver involvement, current services, and home safety.
- Present and discuss initial assessments with the PACE IDT.
- Identify the need for and facilitate additional assessments for prospective participants.
- Collaborate with the IDT to evaluate the ability of prospective participants to safely remain in the community with PACE services.
- Communicate enrollment status and progress to prospective participants and other significant parties involved in their care.
- Facilitate communication among all parties involved in prospective participants' care and the PACE IDT to ensure continuity of care and smooth enrollment transitions.
- Travel locally as required.
- Perform additional duties as necessary.
QUALIFICATIONS
- Associate's or Bachelor's degree in Nursing, or completion of a Nursing Diploma Program.
- Current Registered Nurse license in the Commonwealth of Massachusetts.
- At least one year of experience in geriatric healthcare or adult mental health settings.
- Proficient in advanced computer skills, including Microsoft Office, Customer Relationship Management, and Electronic Medical Records software.
- Effective communication skills to establish working relationships with various medical professionals.
- Ability to respond appropriately to complex clinical situations across diverse settings.
- Strong understanding of medical and psychiatric diagnoses and treatments.
- Experience working effectively with individuals from various socio-cultural backgrounds.
- Ability to assess multiple perspectives and facilitate solutions within a goal-oriented framework.
- Strong customer relations skills.
