Registered Nurses - South Florida
LIFEMASTERS SUPPORTED SELFCARE, INC. (Ft Lauderdale, Florida)

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Join a dynamic, growing high-tech/high-touch healthcare organization that makes a unique contribution to the lives of hundreds of thousands of individuals.

ABOUT LIFEMASTERS:
LifeMasters Supported SelfCare, Inc. is an exciting national disease management company whose mission is to help individuals achieve and maintain optimal health by closing the gaps in medical care and encourage the adoption of healthy lifestyles. With more than a decade of experience, we are experts at delivering disease management services to individuals with chronic diseases such as diabetes, cardiovascular disease, respiratory disease, musculoskeletal conditions and their co-morbidities.

POSITION SUMMARY:

Under general supervision, the Community Services Registered Nurse - Care Manager (CSRN's) role is to provide face-to-face nursing care planning, case management and education to a participant caseload using established ethical, professional, nursing and corporate frameworks and appropriate support to community-based disease management services in the assigned area. Incumbent develops an individualized, educational plan of care for each participant with long and short term goals, routinely assesses the need for plan changes based on participant needs, and is accountable for participant management while the participant is enrolled in the LifeMasters disease management program and acts as a participant advocate, coach, educator and motivator. The CSRN must be culturally sensitive to the local population and job responsibilities include locating and linking participants with the health care services, social services, community organizations, and sometimes back to LifeMasters call center Clinical Nursing Consultants (CNCs), providing or coordinating translation services, and supporting coordination of care and disease management activities. Works with information of a confidential nature and communicates with team members and the participant/family in decision making. Provides support as required to other departments to promote LifeMasters services and performs special projects and other duties as assigned.



PRIMARY JOB DUTIES:

Complete initial screening of participants for assessment of frailty, cognition, nutrition, depression, social and clinical needs. Specific assessment tools used are Identification of Seniors at Risk (ISAR) Screening Tool for safety, TICS-m for cognition, Beck Depression Screen (7 questions screen) for depression and Nutrition Screen.

Conducts home safety assessment of participant home living environment.

For the assigned participant case-load, the incumbent will conduct regularly scheduled visits to develop and monitor care plans, educate, coach and monitor participant compliance and participation in disease management program(s).

Identifies appropriate follow-up services for participants that screens positively. Arrange for any additional in-home clinical and social services that may be required.

Conduct follow-up as well as initial face-to-face evaluations of participants and their living situations. Such evaluations may include a follow-up for possible suitable participants who do not pass certain thresholds conducted via a telephonic screening assessment.

Works closely with participant physicians to facilitate communication and doctor orders for patient education. May visit physician offices to follow up with doctors on participant issues.

Must pay strict attention to follow all HIPAA requirements and LifeMasters company policies regarding the security and privacy of Protected Health Information (PHI) and related internal and external security measures of the same. Must follow and comply with all company policies and procedures in the execution of job duties.

In addition to the above, the incumbent will be responsible for the following job responsibilities:

1. Formulates and implements a nursing plan of care in conjunction with the appropriate disease specific CareMap(s) for each participant and family (or support system) enrolled in the LifeMasters Supported SelfCare Programs.

a. Interviews in a purposeful, goal-directed fashion that encourages the participant and family (or support system) to express ideas, feelings, and facts in order to help identify the participant's needs and goals.

b. Compiles a nursing history utilizing direct and indirect sources of data.

c. Assesses interest, coping patterns, and learning abilities of participant and family (or support system) relative to care.

d. Identifies learning needs of participant and family (or support system) in order to develop and implement appropriate teaching plans, utilizing incidental teaching methods when opportunities arise.

e. Identifies gaps in care.

f. Identifies barriers to learning.

g. Identifies and helps participant implement realistic short and long-term goals related to participant's physiological/psychosocial needs.

h. Assesses and incorporates suggestions of staff/associates when planning care.

i. Ranks and prioritizes participant's needs to establish plan for delivery of care.

j. Involves participant and family (or support system) in the plan of care.

k. Develops individualized nursing plan of care; revises appropriately to reflect current and changing participant status, behavioral and social needs.

l. Identifies and follows through on special participant equipment needs (e.g. pagers, weight scales, etc.).

2. Provides Supported SelfCare interventions to participant and makes substantial nursing judgments through regular home visits, follow-up calls, and alert calls.

a. Assesses participant and family (or support system) coping skills.

b. Integrates knowledge/skills/abilities in providing individualized care and support to participant.

c. Maintains current knowledge base of participant's health status, care, and progress.

d. Monitors, evaluates, and trends participant's responses and progress to goals (CareMap(s), IVR compliance, and program goals).

e. Assists in accessing needed clinical and social resources to address gaps in care and barriers to learning..

f. Responds appropriately to participant alert and emergency situations using appropriate protocols.

g. Alters plan of care in accordance with any needs/changes in participant's physical and psychosocial status.

h. Reports any changes in participant status via an alert call.according to the physician-approved Participant Care Action Plan reporting parameters.

i. Tracks and follows-up on exception reports.

j. Monitors and evaluates participant's completion of surveys (e.g., POV, SF-12, etc.).

k. Seeks guidance from appropriate resources when necessary.

3. Makes assessments continually and systematically to ensure the health care and social needs of participant and family (or support system) are being met.

a. Identifies need for and participates in nursing conferences and/or multidisciplinary team conferences.

b. Documents appropriate participant information promptly, clearly, and completely using LifeMasters approved abbreviations, methodology, and forms.

c. Initiates referrals and utilizes available resources within and outside the Company, and the community to ensure comprehensive care to participant and family (or support system).

d. Assesses participant's progress toward health goals and, when applicable, offers additional or alternative plans of care.

e. Offers suggestions or engages in activities that could enhance the quality of care given to participant, and shares ideas and seeks assistance in experimenting with new ideas.

4. Formulates clear nursing directions in order for other nurses to continue quality participant care in her/his absence and coordinates participant care by providing direction and assistance to other participant care personnel.

a. Ensures work is well organized and priorities are established.

b. Relates complete and pertinent information clearly and concisely in both verbal and written communications.

c. Utilizes inter-and intradepartmental resources in planning participant care.

d. Communicates directly with other members of the team regarding participant's needs.

e. Recognizes and utilizes talents and strengths of personnel to improve care of participants and staff members.

5. Fosters a collegial and collaborative relationship with other health care professionals and assumes responsibility for quality nursing care.

a. Recognizes and responds to verbal and non-verbal communications of participant and family (or support system) and staff members.

b. Preserves participant rights relative to all aspects of care, knowledge, and privacy.

c. Supports appropriate decisions and actions of other staff members.

d. Investigates questionable activities and discusses with the person involved and/or the manager.

e. Asserts self with tact and diplomacy when interacting with other members of the health team.

f. Conducts job functions in a manner that promotes a high level of customer service to both internal and external customers, and supports LifeMasters core values and basic principles.

g. Demonstrates knowledge of current practice changes and protocols; implements changes in a timely manner.

h. Offers suggestions or constructive advice for the improvement of participant care or staff development.

i. Recognizes problems, evaluates facts, and reaches sound conclusions.

j. Problem solves with an understanding of short-and long-term goals.

k. Maintains purposeful activity and order in usual and emergency situations.

6. Maintains competencies and participates in activities which contribute to the ongoing development of self and profession.

a. Accepts responsibility for own practice and development, and participates in activities that further develop professional growth.

b. Demonstrates interest in continuing education through participation in committees, resource activities, etc. offered by the Company or through outside sources.

c. Identifies learning needs and seeks assistance from more experienced staff members, manager, etc.

d. Sets realistic goals for own development based on assessment of strengths and learning needs.

e. Recognizes professional responsibility as extending beyond own group of participants to include goals established for clinical services and the LifeMasters organization.

7. Has a professional commitment to participants and nursing staff.

a. Demonstrates flexibility to departmental needs relative to participant assignment or work schedule.

b. Reports for work punctually and gives adequate notice of absenteeism or tardiness.

8. Adopts CQI principles into all work functions.

9. Performs special projects and other duties as assigned.

PERFORMANCE REQUIREMENTS:

* 2 + years Registered Nurse experience; home healthcare and case management preferred.

* Clinical experience in Cardiac and/or Diabetes preferred. Behavioral health experience preferred. Some locations may require experience to include geriatric or indigent, care.

* 35 wpm typing & solid computer skills required (knowledge of how to use drop down menus, a mouse, maximize and minimize screens, switch between open windows and programs, tab functions, and cut and paste feature)

* Understanding of managed care and disease management from a clinical, contracting and wellness perspective preferred.

* Demonstrated ability to effectively educate adult learners.

* Ability to interact effectively with internal/external contacts, including physicians, nurse practitioners, participants, technical and clerical staff, etc.

* Participant education program management, quality improvement team membership or prior business experience preferred.

* Excellent communication skills, verbal and written, and ability to communicate effectively with individuals from various professional and non-professional backgrounds.

* Ability to plan strategically, to organize and prioritize work, and to exercise initiative to meet deadlines.

* Ability to maintain a high degree of concentration due to complexity and volume of work.

* Ability to be flexible, proactive, and positive and respond to the dynamics of a changing environment.

* Ability to view health care changes as opportunities.

* Preferably reside in and share experience, language and/or culture of the community to be served.

* Must have valid driver's license, reliable transportation and required levels of liability insurance and automobile insurance coverage.

* Excellent interpersonal skills and in-depth knowledge of the community served.

* Bilingual Spanish or Creole may be req'd for some counties.



EDUCATION REQUIREMENTS:

* Graduate of accredited school of nursing

* Must have taken the NCLEX in the U.S.

* Current licensure as registered nurse within the state they will be employed with no restrictions

* Bachelors or Masters Degree in Business or Nursing preferred.

Certificate/License:

* Current licensure as registered nurse within the state they will be employed with no restrictions



BENEFITS:
LifeMasters rewards its employees with a rich benefits package including; 20 days Paid Time Off, Paid Holidays, Medical/Dental/Vision, Cafeteria Plan, Life Insurance, AD&D, Short Term and Long Term Disability Insurance, 401k with Company Match, Flexible Spending Accounts, Domestic Partner Benefits, Education Assistance, Employee Assistance Program, Direct Deposit, Discounted Health Club Memberships, On-site Flu Shots and Health Fairs, and On-line Benefits and Payroll information. LifeMasters recognizes and rewards the diverse needs of its workforce by offering most benefits to Employees who work a minimum of 20 hours per week and most benefits become effective the first day of the month following your date of employment.

LifeMasters offers a fun, caring and casual workplace. In addition, to our comprehensive benefits package, we provide professional development and opportunities for career advancement.



AA/EOE/M/F/V/D