Nurse-AAoA

Overview Announcement # 2025-305 | Issue Date: 10-08-25 | Closing Date: 10-29-25 Nurse Area Agency on Aging Department of Human Services Hourly Wage: $36.11-$40.64/Regular/Full-Time Responsibilities Provides support for clients, including coordinating an array of services designed to improve the health of high needs, high-risk clients. Care coordination responsibilities include assessment, care planning, monitoring of client status, and implementation and coordination of services. Support to clients for effective care transitions, improved self-management skills, and enhanced client-provider communication. Facilitate interdisciplinary consultation, collaboration, and care continuity across care settings. Provide clients, providers, and case managers with health-related assessment consultation to enhance the development and implementation of the client\'s plan of care for TXIX and Home & Community Case Management; perform case management duties and carry a caseload. This position is not a direct care provider of intermittent or emergency nursing care, skills, or services requiring physicians\' orders and supervision. Coordinate follow-up activities and referrals with other programs (e.g., Family Caregiver Support Program and HCS Medicaid Case Management). Provide health-related assessment and consultation in the development of the plan of care through the CARE Tool to case managers. Complete Skin Care Protocol based on the ALTSA Long Term Care Manual. Identify and address barriers to accessing health care and social services. Engage clients in care coordination activities to promote improved utilization of health care services, including maintenance of a patient-centered, goal-oriented Health Action Plan. Assess activation level for self-care using the Patient Activation Measure (PAM). Provide evidence-based health assessments and screenings (e.g., BMI, PHQ-9, Katz ADL, PSC-17, GAD-7, AUDIT or DAST). Provide transition support services that coach the client in four pillars: medication self-management, use of a patient-centered health record, primary care and specialist follow-up, and knowledge of red flags for their condition and response. Work with supervisors and other health care providers, hospital discharge planners, skilled nursing facility staff, and health home staff to implement services and analyze disposition of cases. Perform facility visits, home visits, and follow-up calls to develop coaching relationships and empower clients in discharge planning. Coordinate and communicate post-discharge status with involved health care providers (primary care, mental health, specialty care, pharmacy). Provide referrals and advocacy for clients and caregivers to community-based services and supports (e.g., family caregiver programs, nutrition programs, in-home care, case management). Provide teaching about self-management of chronic health conditions and resource links to ongoing chronic disease self-management support services. Develop and maintain complete and concise client files in compliance with policy for documentation of activities and program requirements. Maintain all required documentation related to services and meet monthly deadlines. Participate in staff meetings, public education, and provider training sessions as appropriate. Develop and maintain relationships with community agencies and organizations that can provide resource support to the program or individuals. Prepare correspondence, memos, and client-related written materials as appropriate. Participate in continuing education and training programs. Work collaboratively with multi-disciplinary teams involving nurses, case managers, and case aides. Attend required meetings and trainings. Knowledge, Skills and Abilities Knowledge of the long-term care system and services, aging and disability issues, and case management. Knowledge of local in-home and community options and resources for the elderly and adults with disabilities and their caregivers. Knowledge of pharmaceuticals and their desired effects or complications. Knowledge of direct functional assessment, service planning, and implementation experience. Computer and software skills including Word, Excel and database systems; ability to operate general office equipment; able to work at a desk using phone and computer for up to a full day. Ability to learn DSHS applications for case management and reporting. Ability to communicate effectively both orally and in writing. Ability to work independently in the field with good judgment and minimal supervision. Ability to work effectively as a team member with diverse staff and community members and to establish and maintain effective working relationships. Ability to plan, organize, prioritize, and coordinate work assignments. Ability to work under pressure within short timelines to implement service plans. Ability to defuse difficult situations with sensitivity and assertiveness. Ability to produce written documents with clear organization, proper English, punctuation, and grammar. Ability to maintain paper and electronic records and report on services provided. Ability to operate standard office equipment. Demonstrated strength in learning and mastering new job responsibilities. Ability to travel to and from clients\' homes and other community agencies that may not be ADA accessible. Minimum Requirements Requires a current Washington State Nursing License as a Registered Nurse with a BSN, or in the process of obtaining an RN, BSN within 3 months of employment. Two years of nursing experience. Maintain 45 CEUs every three years in accordance with the State of Washington. Pass pre-employment background check. Pass pre-employment drug and alcohol test. Must possess a valid Washington State Driver\'s License with the ability to obtain a Yakama Nation Driving Permit. Enrolled Yakama Preference, but all qualified applicants are encouraged to apply. Preferred Requirements Home health and psychiatric nursing background preferred. Training in Coleman CTI or other coaching modality preferred. Experience with cross-disciplinary, cross-organizational teams preferred. Experience meeting and working with people in homes and other medical and community settings preferred. Experience using motivational interviewing or other empowerment-based approaches preferred. #J-18808-Ljbffr