Responsible for assessing the participants’ functional level of care and medical care necessary to determine eligibility for multiple programs and services. Assess individuals to determine what is important to them and complete a person-centered plan of care. The RN will analyze the environment and health conditions of the at-risk participant, coordinate and arrange services for program participants and assist in the Medicaid application process as appropriate. Complete required forms; maintain participant files and related paperwork in a manner consistent with state, federal and agency guidelines and timeframes. Advocate for participants and their allies. Work as a team member in the development and implementation of participant person-centered care plans. Maintain ongoing communications with the participant, their allies and community entities. Ensure the health, safety and welfare of program participants.

Essential Duties and Responsibilities:

• Perform client assessments/reassessments and develop care plans utilizing person centered planning guidelines;
• Utilize strong interpersonal skills that are required to work with participants, allies, agency staff, vendors, and community and government entities;
• Act as a strong client advocate;
• Work with SW team member to determine participants’ medical eligibility for appropriate program enrollment;
• Monitor the nursing facility level of care and functional eligibility at each assessment to assure proper program utilization;
• Comply with state, federal, and agency reporting requirements and mandated response time minimums;
• Develop and coordinate comprehensive community based service delivery in accordance with person centered planning;
• Participate in and represent the agency at all local, state, and federal meetings as required;
• Assist with training or workshops and participate in program presentations as necessary;
• Participate in education and professional development as appropriate and obtain CEUs required for licensure;
• Establish and maintain working relationship with various outside county wide entities such as MDHHS local offices, Community Mental Health, Public Health Department, Senior Center staff, hospitals, home health agencies, probate courts, legal providers, rural health clinics, long-term care facilities, and adult foster care homes;
• Develop and maintain a list of countywide resources and programs, which may benefit clients in need of such services;
• Participate in policy and procedure development as appropriate;
• Maintain client confidentiality at all times;
• Be knowledgeable of and prepared to follow appropriate procedures during an emergency situation in a client’s home;
• Maintain communication with physicians, hospital personnel and nursing home staff as needed to effectively case manage participant’s medical conditions and medication use;
• Perform comprehensive assessments of participant medications, health status, functional abilities and medical history;
• Complete an Emergency Plan with the participant and their allies;
• Extensive travel throughout multi-county service area;
• Prioritize tasks based on recognized standards;
• Maintain professionalism while assisting participants or representing the agency at all times;
• Report any suspected cases of abuse, neglect, or exploitation to the appropriate agency as well as the Community Based Care Supervisor.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.