Home Care Coordinator- RN

About us:

Fallon Health Weinberg is a partnership between Fallon Health of Massachusetts and Weinberg Campus of Erie County, New York. Fallon Health Weinberg offers a Program of All Inclusive Care for the Elderly (PACE) to serve the health needs of dual-eligible residents of the Western New York counties of Erie and Niagara.

Fallon Health is a company that cares. We prioritize our members--always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, we deliver equitable, high-quality coordinated care and are continually rated among the nation's top health plans for member experience, service, and clinical quality. Weinberg Campus has been providing needed services to the elderly for more than 100 years, through both community-based programs and nursing facility care. It is a renowned geriatric education and training institution offering the widest range of housing and care options available on one campus.

At Fallon Health Weinberg, we believe our individual differences, life experiences, knowledge, self-expression and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status and other characteristics that make people unique.

Brief Summary of purpose:

As part of the PACE interdisciplinary team, responsible for the coordination and monitoring of care and services to maintain participants in a safe community environment.

Primary Job Responsibilities:

Review and implement physician's orders.
• Conducts comprehensive nursing assessments including physical, psychosocial, behavioral, and environmental.
• Educates and involves participants and significant other(s) in the plan of care in a manner appropriate for those involved. Interacts with participants and significant others in a culturally sensitive manner. Recommends care and services that are culturally appropriate.
• Monitors and evaluates therapeutic interventions.
• Participate in the development and ongoing review of each participant's care plan.
• Coordinates participants' care responsibilities to other members of the health care team, as appropriate.
• Identifies emergency situations and initiates appropriate nursing interventions and follow-up.
• Meets the needs of participants in a timely manner.
• Participates in the interdisciplinary team (IDT) process and collaborates with IDT members to identify care and services to maintain the participant safe in the community.
• Documents activate related to participant care, including significant changes in health status, monthly nurses' notes, and health teaching in the medical record.
• Participates in training and orientation of new nursing staff as assigned.
• Assists in the delivery of other nursing services as assigned.
• Participates in the nursing "on-call" rotation as assigned.
• Performs all duties in accordance with Fallon Health Weinberg policies and procedures

Education:

Graduate of an accredited school of nursing

License/Certification:

Current license as an RN in the state of New York / CPR certification, or willingness to be certified within 60 days of hire, is essential.

Experience:

At least two years of recent experience in the direct care of adults or chronically disabled persons with at least one year caring for a frail or elderly population.

Ambulatory care or home care experience helpful.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.