This position will ensure the effective and efficient completion of tasks associated with the clinical assessment process, including but not limited to clinical onboarding and reassessment, UAS-NY completion, comprehensive assessment, medication review, and post-hospital discharge evaluation.
Responsibilities:
- Works closely with intake and enrollment and care delivery teams regarding in-home or virtual assessment appointments with prospective or enrolled participants (utilizing the Uniform Assessment System of New York, UAS-NY). During this visit, answers questions about the PACE program and emphasizes the unique benefits of the PACE program.
- Conducts in-home assessments for PACE participants utilizing the UAS-NY to determine initial or continued plan eligibility in accordance with the requirement need of Community Based Long Term Care Long Term Care (CBLTC) Services for greater than 120 days, and care needs.
- Evaluates and reviews previous assessments (of all types) to ensure documentation of any/all changes are accurately reflected in EMR. Must include narrative comments and supporting documentation and escalate issues of significant changes to Care Delivery to provide corrected resources.
- Evaluates and reviews previous primary diagnosis and medications at key intervals to ensure updated documentation is accurately reflected in EMR and match the diagnosis entered into UAS. Update and/or modify diagnosis codes and medication updates and ensure the accuracy of information. Must include narrative comments and supporting documentation and escalate issues of changes to ensure proper care and management of cases are followed.
- Promotes and educates potential referral sources about the PACE program as needed to encourage participation in the program through presentations, lectures, meetings, or other support.
- Educates potential/new PACE participants on plan benefits, services, and care delivery model.
- Escalates questions or concerns during the assessment to the quality review team to ensure appropriate completion of UAS-NY and handling of on-site issues that may require intervention.
- Completes and/or reassesses previous PCAT Tasking Tool to determine appropriate home assistance with ADLs/IADLs combined with attendance at the PACE site. Evaluate and provide recommendations for modifications, corrections, and/or changes to previous evaluations, as well as escalates issues to the discipline manager.
- Develops the proposed service plan and obtains necessary documentation during home visit.
- Utilizes Lenavi analyzer during either the review process and/or assessment.
- Documents all interactions and outcomes in the designated clinical management/electronic record system.
- Completes all assessments, notes, service plans, and other documentation timely (within 48 hours).
- Works with the quality review team to ensure accuracy and completeness of all necessary documentation in the Health Commerce System and in the electronic record system.
- Maintains knowledge of all applicable CMS/PACE guidelines and relevant organizational and departmental policies and procedures, including but not limited to, the timely conduction, finalization, and documentation of the UAS-NY.
- Remains responsive and available by phone/email for contact by staff.
- Must be able to work some weekends and ability to travel to various boroughs.
- Provides significant clinical information to the Care Delivery team in advance of enrollment to ensure a smooth transition and appropriate opportunity for Care Delivery preparation of new participants with complex health conditions.
- Partners with Care Delivery by meeting with site leadership and IDT to provide Clinical Assessment and Intake updates, address concerns and improve the overall process.
- Serves as clinical point person in response to Care Delivery questions, concerns, or issues after enrollment.
- Engages in continuous quality improvement activities to promote optimal staff performance and participant outcomes.
- Advises on operational process improvements that may positively impact enrollment turnaround, scheduling logistics, expense/financial-related efficiencies, engagement strategies, reporting, and other critical touchpoints.
- Regularly reviews key performance metrics and analytics to improve process flows and/or quality of work.
- Maintains a schedule of at minimum two to three (2-3) UAS-NY assessments per day according to the organizations needs and availability.
- Only act within the scope of the individual’s authority to practice.
- Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently.
- Acting member of the IDT.
- Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.
Qualifications:
- Current Registered Nurse NY State License.
- BS in Nursing or other health related area, preferred.
- Three to five (3-5) years in MLTC, LTHHCP, MAP, PACE, or other managed care programs.
- Experience in working independently without significant oversight and or direction from a supervisor.
- Minimum five (5+) years of experience in care/case management,
- disease management, population health management, utilization review, quality assurance, or discharge planning (preferably within a managed care, home care, or community health organization).
- Minimum of one (1) year of experience working with a frail or elderly population or, if the individual has less than one (1) year of experience but meets all other requirements, must receive appropriate training from the PACE organization on working with a frail or elderly population upon hiring.
- Proficiency in utilizing and analyzing UAS-NY and Lenavi.
- Experience with Customer Relationship Management platforms and clinical management systems.
- Be legally authorized (for example, currently licensed, registered, or certified if applicable) to practice in the State in which the healthcare professional will perform the function.
- Be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact.
- Positive attitude and outlook with the ability to multi-task in a constantly changing environment.
- Flexibility one weekend to meet deadlines.
- Highly motivated and self-driven individual with a willingness to work within a strict deadline environment.
- Proficiency in Microsoft Office products; report development and strong writing skills.
- Excellent communication and interpersonal skills are required.
- Customer Service oriented with strong clinical management skills.
- Bilingual skills are strongly preferred.
*Additional Salary Detail
The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member’s base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).
The salary range for this position is $78000.00-$130000.00/year. Salary reflects full-time employment and would be adjusted for part-time or per diem employment based on hours worked.
Salary ranges shown on third-party job sites may not accurately reflect ranges provided by Northwell Health. Candidates should check Northwell Health Careers for accurate information and discuss salary/hourly details and our comprehensive benefits with a recruiter, if selected for an interview.
