Admissions Registered Nurse

Home & Health Care Management is the oldest home health care agency in Northern California. Our agency specializes in delivering comprehensive in-home care and case management for older adults, children, and those living with disabilities across many counties. We use a matrix of Medi-Cal, Medicare and targeted health programs to find solutions that work for our clients. Who You Are: You have a passion to improve the quality of care that patients receive. You want your nursing skills to be valued, and to educate and train caregivers in a home health setting. You want the time to delve into a client’s social determinants of health care and provide real solutions. And you want to work with a great team! Overview of the Role Performs a wide variety of intake and case management activities to applicants/participants in their homes and/or via telehealth to ensure applicants’/participants’ needs are met. If there is any gap in services, ensure the applicable referrals are submitted to the appropriate entities in order to establish care. Intake activities include performing assessments, development and implementation of person-centered Plans of Treatment to enroll applicants into HCBA Waiver (Home and Community Based Alternatives), CCT (California Community Transitions), and ALW (Assisted Living Waiver). Collaborates with a CCT Social Worker (SW) on mutual applicants for CCT and/or ALW enrollments. Also, collaborates with HCBA case management team, which consists of a HCBA Registered Nurse (RN) case manager and two HCBA Social Work case managers, on updating required documents for continued enrollment in HCBA waiver. Responsibilities: To perform this job, you must be able to perform the following duties successfully: - Review of Medical Records including a client’s Plan of Treatment, menu of health services, medication, medical equipment and other community-based services to ensure that the right amount and type of care and products meet the client’s medical needs. - Communicate with providers/ patient participants or health care department or HUD housing representatives both verbally and in written format regarding clients’ care needs. Utilize electronic health record as required by departmental procedures to document all face-to-face or telephone or Microsoft Teams communication with the client, their caregivers, medical providers and social service agencies. - Work with an interdisciplinary team caring for clients enrolled in HCBA waiver, California Community Transitions Program, Assisted Living Waiver Program, or Enhanced Care Management/ Community Supports. - Institute tracking of quality indicators and reports to improve patient outcomes. - Coordinate with HCBA Case Management team members (RN and Social Work Case Managers) via Microsoft Teams or in-person meetings, or joint visits to clients as needed. - Conduct monthly visits with participants via phone, teams, or in person - Performs in-person visits with applicants/ caregivers to complete initial assessment for HCBA waiver. - Responsible for addressing and communicating timely with Department of Health Care Services Nurse Evaluators regarding deferred cases. Essential Requirements: - Current California State license as a Registered Nurse - Valid California Driver’s License - Eligible to be insured under our liability policy with a clean DMV report - Your own vehicle and proof of current auto insurance - Proficiency using software programs, and familiar with Microsoft office product including Word and Excel - Ability to work independently and with others at all levels within the organization and collaborate effectively. - Above-average interpersonal, problem-solving, written and oral communication skills - CPR certificate is required within 30 days of employment Preferred Skills, Knowledge and Certifications - Discharge planning, home health or hospice experience - At least one year of work experience as an RN - Inquisitive nature and analytical skills - CCM certification Se…