AddressCompletes face to face Health Functional Assessments (HFA) to identified members, as directed by DHS guidelines both in the community and health care institutional facilities. Develops a client focused QI service plan collaboratively with primary care physician (PCP) and other decision makers. Assists with access to medical care and services. Coordinates all home community based services, supplies and equipment, for adults and children needing Long Term Support and Services (LTSS) to live independently in the community.
Essential Responsibilities:
- Provides care management (CM) and care coordination to both QI community and institutional members. Completes the Face to Face Health Functional Assessment and Service plan. Care management is provided across the continuum of health care needs - the community, hospital, skilled nursing facility or institution.
- Maintains required documentation using KPHC electronic health record. Updates members service plan, updates and documents assessments and health care in medical records to indicate progress, changes and continuity of care.
- Works closely with the Member Care Services Associate to navigate home community based services, supplies and equipment for LTSS needing members.
- Promotes Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for members 0-20 years of age. Works closely with Member Care services Associates for EPSDT tracking and audits.
- May provide direct patient care per DHS Face to Face HFA requirements.
- May perform patient care to the extent necessary to maintain clinical expertise, competency, and licensing necessary to fulfill job responsibilities and to direct the provision of care on the unit.
- Provides direct patient care on an as needed basis. Provides services that are within scope of license and in compliance with all legal, regulatory, and policy requirements relevant to clinical role performed.
- Incorporates the KP Nursing Vision, Model and Values throughout their Nursing Practice.
