Nurse Care Manager Brockton 40 hour

Job Description HSL provides enhanced housing with services to seniors living in its four 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 Nurse Care Manager is a key member of the housing team working to support residents in living independently, safely, and well for as long as possible by developing meaningful relationships with residents and providing holistic support. The Nurse Care Manager 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. This position will work on-site in an affordable housing community in Brockton, Massachusetts. 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 regarding 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. Follow up on all hospitalizations, rehab stays, and 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. Document all work electronically in shared files/computer programs. 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 the ability to handle difficult situations. Must have compassion for and a desire to work with a senior population. Excellent organizational and interpersonal skills, including the ability to manage multiple projects simultaneously, work efficiently and proactively as part of a team. Excellent oral and written communication skills, including the ability to communicate with residents, families, and staff in a manner that conveys respect, 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. Benefits 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 Salary Range $84,971.00 - $127,458.00 #J-18808-Ljbffr Hebrew SeniorLife