Overview Fairview Partners (FVP) provides high intensity care coordination and case management for seniors and other at-risk populations living in a variety of care settings throughout the 11-county metro area. The FVP Nurse (RN) Care Coordinator provides coordination across all settings of care and performs the functions of case management which include, but are not limited to: assessment, care planning, service coordination and referral, transition management, utilization management and quality assurance. The care coordinator promotes holistic, high quality and cost-effective care with the goal of keeping seniors in the most independent care setting possible. Care coordination for the FVP population is delivered via partnerships with managed care organizations (MCO) and must adhere to regulations set forth by the MCOs, the Minnesota Department of Human Services (DHS), the Minnesota Department of Health (MDH) and the Centers for Medicare and Medicaid Services (CMS). This position will serve Fairview Partners members in St. Paul and surrounding suburbs in the eastern Twin Cities metro area. Responsibilities Job Description Job Expectations: Assessment Conducts annual Health Risk Assessment (HRA) and scheduled follow-up assessments according to MCO, Minnesota Department of Human Services (DHS) and Centers for Medicare & Medicaid Services (CMS) guidelines Performs additional clinical assessments specific to the population being served per professional scope of practice and license Assesses eligibility for State Plan Personal Care Attendant services during HRA, as appropriate; if a licensed public health nurse, may perform assessment independent of HRA Performs pre-admission screening annually and upon transfer to skilled nursing facilities Care Planning Creates person-centered care plan with member including realistic goal-setting and follow-up plan for measuring goal progress Promotes informed choice of benefits, services and health care providers Prioritizes member’s safety and risk mitigation Implementation of care plan via resource referral and communication with interdisciplinary care team Evaluation of care plan including outcome measures and goal achievement Coordination of Medicare and Medicaid Benefits & Services Maintains knowledge of Medicare and Minnesota Medical Assistance health care benefits Provides case management of Elderly Waiver program benefits and services Maintains knowledge of long-term services and supports (LTSS) policy and eligibility criteria Maintains members’ eligibility data in the Minnesota Medicaid Information System (MMIS) Member of Interdisciplinary Team/Facilitator of Communication Actively communicates with other care team members Attends departmental case conferences as requested Attends care conferences Convenes interdisciplinary team members, as needed, for members with complex health care needs Consults with FVP Social Work Care Coordinator for members with complex behavioral or chemical/mental health needs or members needing assistance with financial resources or conservatorship/guardianship Coordinates with other agencies or professionals involved in members’ care, including but not limited to: waiver program case managers, Mental Health Targeted Case Managers, Adult Protection workers, state Ombudsman representatives and county financial workers Transition Management: Actively manages member transitions and communicates across settings to ensure continuity of care Completes required documentation for transitions of care as required by CMS and DHS Attends transitional care conferences Provides discharge follow-up and modification of care plans to ensure members can successfully manage care needs upon return to original care setting Assists members with planning and resources in transitions to new care levels or living settings Additional Responsibilities: Preventative Health Education: Provides education on preventative health measures, as appropriate, for member’s age and health status; promotes managed care health promotion program resources Chronic disease management and minor triage On occasion, delegated medical functions, as ordered or prescribed by a licensed health care provider Mandated Reporting: Reports maltreatment under the Minnesota Vulnerable Adults Act; understands a member’s right to autonomy and self-determination and recognizes reportable risk Advance Care Planning: Maintains knowledge of advance care planning principles; follows Fairview’s system advance care planning policies and procedures to promote a culture of informed health care decision-making that honors a member’s goals, values and beliefs Quality: Carries out activities to support the achievement of outcome measures for the Fairview system, Health Plans, DHS and CMS Additionally, the care coordinator maintains professional boundaries and provides culturally appropriate care. The care coordinator is committed to ongoing professional learning and continually improves his or her practice by attending professional conferences and continuing education activities related to case management and care coordination. Organization Expectations, as applicable: Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served Partners with patient care giver in care/decision making. Communicates in a respective manner. Ensures a safe, secure environment. Individualizes plan of care to meet patient needs. Modifies clinical interventions based on population served. Provides patient education based on as assessment of learning needs of patient/care giver. Fulfills all organizational requirements Completes all required learning relevant to the role Complies with all relevant laws, regulation and policies Performs other duties as assigned. Qualifications Required Education Bachelor’s degree in nursing or equivalent: Associate Degree in nursing with two years of experience. Experience One to three years of clinical nursing experience. Critical thinking and ability to work with patients with complex health and psychosocial issues a must. License/Certification/Registration Minnesota Board of Nursing RN license in good standing Preferred Education Bachelor’s degree or higher in nursing Experience Three to five years of experience in geriatric nursing, public health or care coordination/case management. Strong knowledge of managed care programs, long-term services and supports, Medicare and Medicaid benefits and senior care industry License/Certification/Registration Minnesota Board of Nursing Public Health Nurse license Certification in case management, gerontological nursing, or public health nursing Additional Requirements (must be obtained or completed within a period of time): Basic computing skills including keyboarding, Microsoft Word, Outlook and Excel and Adobe Acrobat; demonstrated proficiency with electronic medical record systems; excellent written and verbal communication skills EEO Statement EEO/AA Employer/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status