Nurse Care Manager Brockton 40 hour

Responsibilities

• Partner with the Wellness Coordinator and the resident services team to provide comprehensive case management services to residents.
• Provide regular preventative outreach to all residents to check in on their needs and overall health and develop trusting relationships with residents and their families.
• Conduct wellness assessments of residents to assess risk and determine needs.
• Actively follow up on all identified needs including finding resources, making referrals and ensuring residents are actively engaged in services.
• Assess resident medical concerns and support residents with decision making re next steps, e.g. calling PCP, going to urgent care, going to the ED or seeing a specialist.
• Coincordinate with primary care physicians and specialists, hospitals, mental health and other community providers.
• Ensure effective communication around changes in status, transitions and service utilization.
• Active follow up on all hospitalizations, rehab stays, emergency room visits.
• Work with families, hospitals, rehabs, HSL Home Care and/or VNA, ASAP’s and other providers to ensure safe discharges and ongoing services.
• Follow up regularly with at risk residents to support adherence to health and wellness related activities, medication and treatment plans.
• Conduct and/or coordinate group and individual education sessions on health and wellness, including medication management.
• Assess and keep track of the needs of residents with special needs, such as dementia and mental health, and make appropriate referrals.
• Utilize collected data to identify, plan, schedule and implement focused programs, such as falls prevention.
• Support and educate housing staff members about common medical conditions and how to identify and communicate status changes.
• Participate in resident services team meetings, provider meetings and individual family meetings.
• Assist residents and family members with transition to other levels of care when needed.
• Assist with specific resident needs such as taking vital signs, educating and assisting with Health Care Proxy and File of Life forms, arranging clinics for vaccines and arranging other health focused clinics, supporting residents in preparing for planned surgeries/medical tests.

Qualifications

• RN and 1 year of experience or LPN and 2 years of experience required.
• 3 years experience in aging services required, home health experience and dementia care a plus.
• Excellent triage and critical thinking skills required as well as ability to handle difficult situations.
• Must have compassion for and a desire to work with a senior population.
• Excellent organizational and interpersonal skills, including ability to manage multiple projects simultaneously, work efficiently and proactively as part of a team.
• Excellent oral and written communication skills, including ability to communicate with residents, families and staff in a manner that conveys respects, caring and sensitivity.
• Motivated to learn and flexible/willing to change.
• Professional, proactive, collaborative, conscientious, and results-oriented individual.
• Optimistic and positive demeanor, good intuition and sound judgment.
• Must be able to collect needed information and document clearly in electronic formats.
• Skills and comfort using Windows, Word and Excel required.
• Experience in aging services strongly preferred in community, home health or long-term care settings.