POSITION: CSSM/CAE Registered Nurse
(Comprehensive Screening and Service Model/Clinical Assessment and Eligibility RN)
The CSSM/CAE RN is responsible for pro-actively assisting nursing facility residents return to the community in the least restrictive setting in collaboration with the CSSM CM and nursing facility staff by providing support and education regarding community service options for the MassHealth member/applicant, family members and caregivers. The RN also performs MassHealth screenings to determine clinical eligibility for specific programs as well as perform administrative input of screenings done by RN CMs in delegated hospitals.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
Perform weekly visits to assigned Nursing Facilities, meet with facility SW/Discharge Planner to discuss status of consumers requiring follow up and/or potential discharges and visit all dually eligible consumers / MassHealth members/applicants, within 10 business days of their admission.
Review consumers clinical records and meet with direct care staff to obtain current status of consumers.
Perform personal interviews with consumers unless their cognitive status prohibits the interview, for all requiring a Level of Care (LOC) determination.
Determine need for additional short term stay (STA) in the nursing facility if consumer requires more time to meet defined goals for discharge, issue a nursing facility approval (LTA) after one or more STAs if barriers to discharge cannot be overcome or issue a denial if consumer no longer meets nursing facility eligibility criteria.
Work closely with the CSSM CM who must be involved in all aspects of service planning for consumers.
Complete Case Closure Forms for consumers who have been successfully discharged as a result of efforts made by the RN and CM and for which barriers have been overcome, to provide them the highest quality of life in the least restrictive setting.
Prepares all necessary documentation regarding consumers appealing a LOC decision and attends and presents rationale for decision at the Board of Hearings.
Completes CAE screenings, i.e. Community Screenings for Nursing Facility Admission, initial Program for All inclusive Care of the Elderly (PACE), Adult Day Health (ADH), Acute In-Patient Hospitals (AIH) and non- Acute In-Patient Hospitals (non AIH) for MassHealth members and applicants.
Deals with health care providers and community agency staff in clarifying regulations, answering questions and providing instruction.
Works collaboratively with the CAE Assistants responsible for processing all screenings.
Participates in agency meetings, committees, task forces, training and workshops as needed.
Other duties as assigned.
Must possess a valid Massachusetts license to practice as a Registered Nurse.
A valid Massachusetts motor vehicle license.
Must have demonstrated leadership ability.
Must be able to work with a diverse team.
Must be organized and detail oriented.
Possess working knowledge of community resources and reimbursement systems for health and social services.
Basic computer skills required.
EDUCATION, SKILLS, AND EXPERIENCE:
A Bachelors Degree in Nursing or Human Services and a minimum of three years clinical experience, one of which must have been in a community setting or
An Associate Degree or Diploma in Nursing and two additional years of community- based nursing experience or long term care direct service experience.
Two years of Long Term Care experience and/or two years of Home Care experience strongly preferred
PHYSICAL REQUIREMENTS OF THE JOB:
Ability to lift and carry objects frequently weighing up to 10 to 15 pounds.
Ability to climb stairs.
Ability to travel to the community to perform visits at consumers home.
Work requires regularly standing, stooping, and bending.Company Description
Since 1974 Central Boston Elder Services has been helping seniors live independently, and with dignity. Extensive in-home services, ranging from personal care to home delivered meals are available. Eligibility for services is based on a sliding scale and is determined by age, income and need. Most Boston residents qualify to receive services at little or no charge.
We offer extensive benefits which begins on the first day of employment: Health Insurance, Dental Insurance, 403(b) Retirement Savings Plan with employer contribution, Health Reimbursement & Flexible Spending Accounts, Life Insurance, Short and Long Term Disability Insurance(s), Paid Vacation, Holidays, Personal and Sick days, Tuition Assistance, Employee Assistance Program, and much more.