You may think “old” when you think of Institute on Aging because we offer services for elders and are a 40+ year institute…. but you wouldn’t be more wrong. While we do have a long-standing history in the Bay Area, IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the “status-quo” and create new and more innovative ways to help aging adults maintain their quality of life. With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence, and participation in the community, fulfilling our mission.
Community Living Services (CLS) is an innovative and revolutionary healthcare model that allows adults with disabilities as well as seniors to live at home longer by transitioning them out of nursing homes and back into the community by partnering with health plans and Medi-Cal. This inventive, nationally recognized model is one of the most promising for seniors to date, transforming their lives by providing them with a higher quality and more independent life and saving millions of dollars for healthcare systems. CLS is IOA’s fastest growing division, expanding throughout California. Its employees are dedicated and forward-thinking professionals with a passion for building seniors a better world.
The MSSP Department, which is part of the CLS organization, is seeking a Per Diem Nurse Care Manager, to join its team in San Francisco covering the San Francisco/San Mateo region. The Nurse Care Manager’s primary responsibility is conducting health assessments, enrollments, and reassessments of clients with
multiple medical and psychosocial problems. Identifies the health and functional limitations of
clients that impede independent living. Provides health education and consult to team members.
Responsible for the certification and annual recertification of clients’ level of care determination.
Provides case management services for a specified client case load ensuring provision of quality of care.
- Conducts comprehensive health assessments and reassessments to identify the health, medical, psychosocial, environmental, rehabilitation, and spiritual needs of clients, and gaps in care with existent support systems.
- Coordinates and implements, with the Social Work Care Manager, the timely scheduling of intake and health assessments/enrollments at the start of every month.
- Writes health assessments consistent with the guidelines in the MSSP site manual to be client-centered and comprehensive, and completed and submitted in a timely manner according to guidelines outlined in site policy and procedures manual.
- Certifies clients’ level of care by determining eligibility according to Title XXII guidelines outlined in the MSSP site manual.
- Provides health education and consult to team members in weekly care plan conferences and as needed; collaborates with Social Work Care Manager in the development of client service plans.
- Writes comprehensive and client-centered service plans combining the needs idenified in the health and psychosocial assessment and reflects all services and resources needed to support the client to live independently in the community; service plans are documented in a clear, concise, and organized manner according to MSSP guidelines.
- Identifies, arranges for, and monitors appropriate community services with a good knowledge of Medicare, Medi-Cal, and other entitlement programs.
- Assumes case management responsibilty for clients specified to have complex health issues.
- For assigned case load, provide monthly phone contact, and home visits as needed and at least once every three months, to monitor provision of all components of care on an ongoing, at minimum monthly basis.
- Provides health education and consult to clients, caregivers, family and support sytems to promote medical care compliance.
- Documents all case management acitvity in a timely manner consistent with site policy; identifies any new problems or changes in client’s mental, physical, psychosocial, and spiritual status and adds to service plan as needed.
- Establishes and maintains a therapeutic relationship with clients; treats all clients and their support systems with respect and dignity; provides supportive, empathic, and consistent counseling and coaching; sets limits and maintains professional distance; confronts the important problems and follows through with therapeutic interventions in a timely manner. Provides crisis intervention and advocacy when necessary.
- Provides as needed housecalls for health and medical problem assessment of assigned clients on caseload and of team member’s clients; interprets clinical findings and assist with consult and communication with physicians and other health care providers.
- Maintains required paperwork/client forms and follows a clear, concise, and consistent system of charting to allow for continuity of care according to State and Federal regulations.
- Adheres to MSSP and Institute on Aging’s Safety Policies and Procedures to assure personal safety on each home visit.
- Initiates original service planning for assigned clients, documenting purchased services justified in service plan according to MSSP guidelines. Verifies/authorizes start of client’s use of purchased service according to site policy by signing Service Utilization Form (SPUS) per contacting the client on a monthly basis.
- Participates in research studies and data collection, as required.
- Participates in quality assurance and annual peer review/staff evaluations according to site policy.
- Establishes and maintains open and effective communication with community providers, including physicians and other health care and social service providers. Provides appropriate information on all significant aspects of individual client care and program operations, while maintaining necessary confidentiality.
- Contributes to the effective functioning of the MSSP team through attendance and constructive participation in meetings, required and preferred trainings, activities, and problem-solving and goal-oriented endeavors.
- Utilizes supervision appropriately; maintains open lines of communication to update supervisor on caseload activity; seeks consult as needed in a timely manner.
- Continuously evaluates the clients’ case management needs to remain safely at home, and refer client for placement and terminate cases when appropriate according to MSSP guidelines.
- Actively incorporates the ethical standards of the American Nurse Association in all aspects of interactions with others.
- Assumes responsibility for mandated reporting of client abuse.
- Understands and applies the regulatory and procedural requirements of MSSP, as well as the policies and procedures of the Institute on Aging.
- Identifies annual goals/objectives relevant to enhancing the role and function of the health practitioner and care manager.
- Attends continuing education classes and/or in-service trainings to increase knowledge, skills and attitudes related to case management, gerontology, family and community systems and other areas relevant to the MSSP client population.
- All other reasonably related responsibilities as assigned.
- Current California RN licensure required, plus one year experience performing registered nursing functions.
- Minimum 2 year experience working with geriatric population preferred, 1 year
- Demonstrates understanding of normal aging and health care, case management, and rehabilitation, psychosocial, health, and medical issues relevant to the frail and aging population.
- Demonstrates knowledge of community resources.
- Good oral and written communication skills.
- Bilingual preferred.
PHYSICAL & OTHER REQUIREMENTS:
- Ability to lift, transfer, push/pull, maneuver, and reposition up to 25 lbs.
- Ability to reach, bend and walk
- Five finger manipulation
- Ability to comprehend complex written material and verbal instructions.
- Ability to speak and write English clearly, second language helpful
We encourage you to learn more about IOA by logging onto www.ioaging.org
IOA reserves the right to revise job descriptions or work hours as required
Institute on Aging is an Equal Opportunity Employer. Institute on Aging is committed to cultivating a diverse and inclusive work environment and providing equal opportunities to all employees and job applicants without regard to age, race, religion, color, national origin, sex, sexual orientation, gender