Nurse Care Manager

Revere, MA, United States

Overview:

HSL provides enhanced housing with services to seniors living in its three affordable housing locations, and at partner housing sites, with the goal of improving quality of life and supporting independent living. At its core, enhanced housing with services is a proactive approach wherein resident services staff regularly and actively reach out to each individual resident to engage with them around their health and wellness, identify areas of need/risk and provide intensive, individualized case management and support as needed and desired by the resident.

The Wellness Nurse is a key member of the housing team working to support residents in living independently and safely for as long as possible by developing meaningful relationships with residents and providing supports in a holistic way. The Wellness Nurse works closely with other team members to: engage residents in wellness assessments and health education programs, connect residents to needed services, triage resident issues, provide a wide variety of case management tasks including coordinating care for residents returning home from hospital and/or rehab stays, ensure that all interventions are documented and tracked, and partner with community provider organizations.

Hebrew SeniorLife employees set the highest standard in our commitment to redefine the experience of aging. With compassion, resilience, and determination, we make a difference in the lives of patients, residents, their families, and the broad senior care community every day. And they in ours as well. These life-changing connections give our work meaning and fuel our desire to advance our potential. To be all that we can be. At Hebrew SeniorLife, thats uniquely possible. Because here were supported to always keep growing. And as we do, so does our collective impact.

Our benefits include:

Excellent medical and dental benefits, available on your first day for positions over 24 hours/week

A 403b retirement plan open to all employees, including per diems

Generous paid time off

On-site health and wellness programming

Tuition reimbursement and scholarships

An employee recognition program

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.

Coordinate 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, ASAPs 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.

Document all work electronically in shared files/computer programs.

Required 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.

Preferred Qualifications: Experience in aging services strongly preferred in community, home health or long term care settings.

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