Job Responsibilities:

• Conduct Assessments: Perform in-home or virtual assessments for PACE participants using the UAS-NY system. Explain the benefits of the PACE program and answer questions from prospective or enrolled participants.
• Evaluate Eligibility: Assess whether participants qualify for PACE and Community-Based Long-Term Care (CBLTC) services for over 120 days.
• Update Records: Review and update participant records in the Electronic Medical Record (EMR) and UAS-NY. Ensure all changes are documented accurately and escalate major issues to the Care Delivery team.
• Manage Diagnoses and Medications: Check and update diagnoses and medication records. Make necessary adjustments and ensure accuracy in EMR and UAS-NY.
• Promote the Program: Inform potential referral sources and new participants about the PACE program through presentations and meetings.
• Ensure Quality: Address any questions or issues during assessments by working with the quality review team to ensure accurate and complete documentation.
• Develop Service Plans: Create service plans during home visits and use the Lenavi analyzer as needed.
• Document and Report: Keep detailed records of all interactions and assessments, ensuring timely documentation within 48 hours.
• Stay Informed: Keep up with CMS/PACE guidelines and organizational policies to ensure compliance.
• Be Available: Respond to staff inquiries, work some weekends, and travel as needed.
• Collaborate: Provide information to the Care Delivery team for smooth participant transitions and work with site leaders to improve processes.
• Improve Processes: Participate in quality improvement activities and suggest ways to enhance efficiency in enrollment and scheduling.
• Monitor Performance: Regularly review metrics to improve processes and maintain a schedule of 2-3 assessments per day.
• Other Duties: Perform additional tasks as assigned.

Schedule: 8:30 AM – 5:30 PM

Weekly Hours: 40

Qualifications:

• Education: BS in Nursing or a related health field preferred.
• Experience:
• At least one year working with elderly or frail populations (or equivalent training).
• 3-5 years in managed care programs like MLTC, LTHHCP, MAP, or PACE.
• 5 years in care management or similar fields.
• Experience with UAS-NY and Lenavi, and familiarity with CRM and clinical management systems.
• License: Active NYS Registered Nurse license required.