Registered Nurse - Home and Community Care

Job Summary

This position performs highly responsible and professional level nursing involving assessment, support planning, case management services for Scott County residents utilizing a CAC, CADI, EW, AC or BI waiver, and eligibility determination for publicly funded long term care services and support programs for seniors and persons with disabilities. Work is performed in an office, institution, community, home, school, or community-based setting.

Job Description

ESSENTIAL DUTIES

• Conducts a holistic assessment of client/family needs in order to: identify health and safety issues of the client and the impact of those issues on the client, identify client's strengths, needs, motivation, and capacity for change in a culturally sensitive manner using professional judgment.
• Analyzes assessment data and assists applicants in identifying relevant goals along with specific supports that will enhance clients’ abilities to meet goals and live as independently as possible.
• Determines applicants’ risk of institutional care and their level of care according to state and federal criteria.
• Determines eligibility for home and community-based programs (AC, BI, CAC, CADI, DD, EW waivers, and PCA) based on individualized client needs and wants.
• Provides health consultation and education on individual, and community levels through direct client service, collaboration with other health care providers, and by participating in meetings/task forces, to plan for and ensure service coordination with community agencies.
• Performs/implements public health emergency response functions as trained and assigned within the federal, state and county’s emergency response plans.
• Analyzes and interprets diagnostic evaluations, medical information, and assessment results enable to determine program eligibility and support decision making.
• Communicates state and federal program requirements, eligibility results and availability of services to clients, their family members, legal representative, community members, and service providers.
• Develops and implements person centered care plans to ensure achievement of timely client outcomes.
• Provides professional case management to program-eligible recipients by monitoring and evaluating the appropriateness, effectiveness, and quality of services provided to the client; identifies when gaps in services exist and makes certain services are delivered as authorized.
• Develops and maintains knowledge of other resources in the county, region, and/or state; networks and collaborates with community partners and others to develop additional options for clients; advocates on behalf of clients.
• Provides education, skill development, problem-solving, and support to clients and their families to empower and enable them to live independently; advocates for clients to maintain quality services and programs.
• Collaborates with Adult and Child Protection Workers in the development of safety plans to address the safety needs of vulnerable adults/children in current adult/child protection/child welfare cases as requested. Additional collaboration with county wide departments to meet the needs of clients may be required.
• Engages in case-planning activity to include:
• Identifies client's and community's priorities and the desired outcomes.
• Identifies strategies and resources to be used in attaining the outcomes.
• Develops person-centered plans to ensure the safety of the client and of the community
• Ensures proper resource allocation and that services are cost effective.
• Reduces the fragmentation of services to the client.
• Maintains and records case notes to follow progress of client and/or case; maintains program data in a retrievable format to support required reporting; writes specific reports/assessments as required; coordinates service agreements to ensure provider payment.
• Provides professional case management to program-eligible recipients by monitoring and evaluating the appropriateness, effectiveness, and quality of services provided to the client; identifies when gaps in services exist and makes certain services are delivered as authorized.
• Intervenes in times of crisis assisting clients with needs and/or procuring the proper help for them.
• Consults with, informs, and educates different audiences about programs and services.
• Drives a vehicle to transport self to client related meetings. Occasionally, transportation may include clients as it relates to service coordination.
• Must work the days and hours necessary to perform all assigned responsibilities and tasks. Must be available (especially during regular business hours or shifts) to communicate with other employees, supervisors, customers, vendors, and any other person or organization with whom interaction is required to accomplish work and employer goals.
• Performs other related duties as required or assigned.

MINIMUM QUALIFICATIONS

*Program requirements/rules dictate the experience requirement reflected in this job description.

Case Management:
Requires licensure as a Registered Nurse (RN) in the state of Minnesota, Cardiopulmonary Resuscitation (CPR) certification, and two years of RN experience. 

MnCHOICES Assessor:
Registered nurse with at least 2 years of home and community-based experience.
Social Services Information System (SSIS) or Department of Human Services (DHS) program training regarding home and community-based waivered services and experience with Medicaid Management Information System (MMIS) are highly desirable. One must possess a valid driver's license and a reliable means of transportation for the performance of work.

SUPERVISORY CONTROLS

The employee is under general guidance and direction from the Social Work Supervisor or Public Health Supervisor when performing duties on behalf of the Public Health Department. Work is performed according to established professional guidelines and procedures, as well standards and procedures which are determined by county, state, or federal regulations. The employee exercises considerable independent judgment in implementing new work methods and procedures. Work is reviewed through case/clinical record reviews, peer reviews, case consultations, community or system wide initiatives, possible co-visits with supervisor, and DHS Lead Agency Reviews.

CORE COMPETENCIES AND ABILITIES

• Customer Service - Delivers government services in a respectful, responsive, and solution-oriented manner.
• Communication - Is always clear about what we're doing and why we're doing it.
• Collaboration - Works with partners – communities, schools, faith groups, private business, and non-profit agencies – to see that services are not duplicated but rather are complimentary, aligned, and provided by the partners who can deliver the service most effectively.
• Stewardship - Works proactively to make investments, guided by resident input, which will transform lives, communities, and government.
• Empowerment - Works with individuals and families to affirm strengths, develop skills, restore hope, and promote self-reliance.
• Resiliency - Fosters public preparedness and responds when families and communities face health and safety emergencies.
• Innovation - Takes informed risks to deliver services more effectively and learns from successes and failures.
• Knowledge of the principles, practices, and techniques of case management, nursing, and public health.
• Knowledge of federal and state laws and regulations related to nursing, public health, and social work case management.
• Knowledge of ICD-9 codes.
• Knowledge of agency programs, operations, policies, and procedures.
• Knowledge of nursing assessment skills in relation to health promotion, wellness, and prevention strategies.
• Knowledge of the functions of other health, social services, and community agencies and their relationships to public health programs.
• Knowledge of documentation techniques.
• Knowledge and understanding of and respect for the diversity of customers, co-workers, and supervisors, including individuals with a disability or whose first language may be other than English.
• Knowledge and understanding of human behavior, cultural diversities, and langue barriers to ensure equitable service delivery.
• Knowledge of conversational interviewing techniques and skills.
• Knowledge of person-centered planning principles and practices and incorporate them into assessment and care plan development.
• Ability to maintain records regarding case work.
• Ability to analyze complex case situations to evaluate the need for support services.
• Ability to engage others in activity that supports self-care and personal safety.
• Ability to problem-solve and advocate on behalf of others.
• Ability to exercise good judgment in making decisions and determining when additional case review or action is needed.
• Ability to follow complex verbal and written instructions.
• Ability to assess individual's and family's needs and to develop and implement interventions.
• Ability to make independent decisions within community health nursing practice standards.
• Ability to keep detailed records, adhere to documentation guidelines, and prepare reports.
• Ability to determine program eligibility.
• Ability to prioritize, assess, and manage assessment/case management workload.
• Ability to use MS Office software, technology and applications needed for the performance of essential duties.
• Ability to use appropriate discretion in dealing with matters of a confidential nature.

WORK ENVIRONMENT AND PHYSICAL DEMANDS

Typical characteristics of the regular, ongoing work environment of this position requires inside work, occurring both in an office and in the field in community-based settings. The position is multi-task oriented and includes periods of stress when balancing the needs/demands of multiple clients. One may be exposed to agitated, upset, socially inappropriate or aggressive clients; out of control children and pets; various atmospheric conditions such as COVID, bed bus, lice, fleas, bodily fluids, poor ventilation and other unknown conditions in home-based settings. Evening and weekend hours may be required for accomplishing this work.

Physical activities include sedentary to light work: Reaching, sitting, standing, walking, pushing, lifting, pulling, fingering, grasping, feeling, stooping, talking, hearing, seeing, and repetitive motions. Lifts and/or navigates up to 35 pounds on a routine basis in handling files, equipment, and items related to client care necessary for performing the essential duties of the job.

SELECTION PROCESS

Selection for this position will be based on a minimum qualifications screening and rating of training and experience. Top candidates will be forwarded to hiring manager or supervisor for consideration for interview and/or additional assessments. Final selection will include a background check and approval by the County Board.