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RN - Transition of Care Nurse - Elder Service Program (PACE) !

Company: Fallon Community Health Plan
Location: Buffalo
Posted on: September 25, 2022

Job Description:

RN - Transition of Care Nurse - Elder Service Program (PACE) !

US-NY-Amherst, NY

Job ID: 6806
Type: Full Time
# of Openings: 1
Category: Nursing
Fallon Health Weinberg - Buffalo


About Fallon Health: Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon delivers equitable, high-quality coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter, and LinkedIn. About Fallon Health Weinberg - PACE: Fallon Health Weinberg-PACE is a long-term care program for older adults who need a nursing home level of care, but wish to stay living at home and in their community. We are a Program of All-inclusive Care for the Elderly (PACE), providing complete medical care and support services so you or your loved one can remain living safely at home. All care is coordinated and provided by an interdisciplinary team specializing in geriatric care, who work with participants and their caregivers to create an individualized care plan. Summary: Evaluates and assesses prospective PACE enrollees provided by the outreach. Confirms that prospective enrollee's meet the eligibility requirements for the PACE program through utilization of the NYS assessment tool (UAS), and presents information to the Interdisciplinary Team in an accurate and concise manner. Keeps the team informed of issues that affect enrollment decisions and maintains data. Ensures that participants' transitions of care to and from inpatient facilities are appropriate, timely, and successful. The TCC nurse participates on the Utilization committee to help achieve program business goals. Responsibilities

Primary Job Responsibilities:

  • Attends IDT meetings to discuss inpatients, barriers to discharge or transition, and suggest discharge plans
  • Uses a checklist to ensure that the components of a safe transition of care occurs
  • Visits participants at inpatient facilities as needed to be up to date with their functional and medical status and rehabilitation needs
  • Talks daily with primary team members to address potential barriers to discharge or transition to lesser care setting
  • Recognizes, identifies, and implements appropriate opportunities to help meet Utilization goals
  • Knowledge of managed care, quality, and risk management principles
  • Participates in the Utilization Committee
  • Documents all inpatient care transitions and case management progress notes within the electronic health record
  • Attends family meetings as needed
  • Completes the UAS, estimates whether individual meets clinical criteria for enrollment, and enters MDS state system.
  • Communicates with the Interdisciplinary Team to provide information for enrollment decisions and provides ongoing communication with referral sources, potential enrollees/families during the intake process.
  • Coordinates and communicates necessary information about potential enrollees to the Site Director on an ongoing basis.
  • Assist with completion of UAS assessments annually


    Education, License, Certifications, and Experience:
    • Bachelor of Science in Nursing
    • Reliable transportation required
    • Two years nursing experience with at least one year of experience working with a frail or elderly population. Experience in or with long term care facilities and experience with home care desired. Knowledge of Utilization Management principles. Experience with UAS preferred. Fallon Health Vaccination Requirements: To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022, all roles not designated as "Remote" require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment. Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. PM16 PI191368408

Keywords: Fallon Community Health Plan, Buffalo , RN - Transition of Care Nurse - Elder Service Program (PACE) !, Other , Buffalo, New York

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