MDS RN - Enrollment

GENERAL SUMMARY

Functions as an integral part of an enrollment team to prioritize, organize, and adapt the PACE enrollment process to meet potential participants’ individualized needs and to ensure census goals are achieved. Works as a clinical liaison between prospective participants/caregivers, the PACE enrollment team, the PACE interdisciplinary Team (IDT) and referral sources/other community providers.

ESSENTIAL RESPONSIBILITIES

Enrollment Team Responsibilities

• Conducts initial appointments to describe PACE model to potential participants and their caregivers
• Ensures potential participants meet eligibility criteria in accordance with PACE enrollment regulation
• Uses a strength based approach to evaluate current needs and health status of potential participants
• Proactively communicates with the IDT regarding current enrollment status and progress of prospective participants
• Mediates and prioritizes between prospective participants’/caregivers’ needs and the IDT’s concerns
• Participates in weekly Enrollment Team meetings to provide clinical insights, advice and additional support regarding challenging referrals and other barriers, and conflicts that may arise
• Complies and maintains accurate data on new referrals in the CRM, EMR software and Masshealth Virtual Gateway
• Coordinates and assists Marketing and Outreach with outside events

Nurse Coordinator Responsibilities

• Visits prospective participants in their home settings to complete and subsequently submit the state required Minimum Data Set- Home Care (MDS_HC)
• Completes comprehensive needs/medical assessment intake, including an evaluation of current functional status , caregiver status, current services and home safety
• Presents and discusses initial needs assessment intake with the PACE IDT
• Determines need for and facilitates additional assessments of prospective participants
• Collaborates with IDT to assess prospective participants’ ability to remain living safely in the community with PACE services
• Communicates enrollment status and progress with prospective participant and other significant parties involved in prospective participants’ care; caregivers, referral sources, homecare providers, case managers etc.
• Bridges communication between pertinent parties involved in prospective participants’ care and PACE IDT to facilitate continuity of care/ smooth enrollment transitions
• Frequent local travel
• Performs other duties as required.

JOB SPECIFICATIONS

• Associate’s or Bachelor’s degree in Nursing, or completion of a Nursing Diploma Program
• Licensed as a Registered Nurse in the Commonwealth of Massachusetts
• Minimum one (1) year experience in a geriatric healthcare and/or adult mental health setting
• Advanced computer skills, including Microsoft Office, Customer Relationship Management, and Electronic Medical Records software
• Ability to communicate effectively with and establish working relationships with various medical licensed personnel
• Ability to appropriately respond to complex clinical situation in a variety of settings
• Strong knowledge of medical/psychiatric diagnosis and treatments
• Experience working competently and comfortably with individuals from diverse socio-cultural backgrounds
• Ability to assess multiple perspectives and priorities and successfully facilitate within a goal oriented/solution focused framework
• Skilled customer relations