The Clinical Assessment RN gathers referral information and makes a determination that the member may be appropriate for MLTC. The documentation is processed and a Nurse Assessor makes a home visit for the purpose of enrollment assessment to determine clinical eligibility for enrollment and works with the enrollment team to make enrollment decisions and develop care plans. Also conducts reassessments of MLTC members in their homes to determine continuing eligibility and identify any needed changes to care plans, reports findings to Care Management Team.
Documents all in Tru-Chart March system of record.
May also conduct PRI (Patient Review Instrument) assessment and screen if properly certified to do so.
Conducts enrollment assessments to determine clinical eligibility
Explains ArchCare Community Life Plan features and benefits, including explanation of the member's handbook.
Completes UAS – NY Assessment instrument along with Archcare assessment workbook all enrollment documentation.
Make an enrollment decision and develop an initial care plan for the prospective MLTC member.
Maintains frequent communication with the Enrollment Department and Care Management to keep ArchCare Community Life a primary option for care delivery.
Coordinates transition of services from prior care provision to ArchCare Community Life.
Identifies any barriers to enrollment and and Care Plan and initiates interventions.
Communicates with the Care Team in conveying information about the new enrollee to facilitate any concerns, or answer questions.
Completes UAS – New York Assessment instrument along with Archcare assessment workbook for MLTC members as assigned to determine continuing eligibility and / or identify any needed changes to Care Plan.
Performs other related duties, as required.
Experience in Home Care, geriatric care, discharge planning, case management, or long term home care.
One (1) year of experience working in a community based program caring for older adults.
Demonstrated skills in planning, organizing and directing the work of others required.
Experience in Intake or an admission team of an MLTC, CHHA, or LTHHCP is highly desirable.