About the Role : PER DIEM

Our company is growing, and we believe that our employees are the key to our success. That is why we are looking for a PER DIEM field MDS Assessment RN with a health maintenance mind-set, experienced community nursing case management, patient advocacy, caregiver education, and preventive measures to service our clients in Western Mass and surrounding areas. If you're a passionate, caring, and motivated professional who is looking to become part of an awesome organization while making a difference in your community, we encourage you to apply today!

About Us:
Vitra Health is a Home Health Care and Adult Day Health organization that specializes in care management of adults and seniors. We rate ourselves solely by the quality of care we provide our clients. We realize that our clients are someone's parent, grandparent, child, friend, or neighbor – we pride ourselves on never taking this fact for granted. Our company is rapidly growing, and we believe that our team is the key to our success! We are looking for a motivated, organized, and patient first-oriented MDS Assessment Nurse to support our communities and mission!

Essential Functions:

• Assists the program director in administrative duties while overseeing the Personal Caregiver's in the home setting environment based on Group Adult Foster Care and Adult Foster Care guidelines.
• Directs and supervises personal care staff and other social services; orientating and training of personal care staff
• Evaluation of all potential clients: assessments and admissions of clients
• Contact with client's primary care physician to obtain medical information and physician clearance; also reporting any changes in medical status
• Completion of all components of the client's assessment forms
• Developing and reviewing on an ongoing basis each member's AFC and/or GAFC plan of care
• Monitoring of the client's health status and completion of the semi-annual client health status report (PSF), the annual MDS, RFS, the client care plan and all other applicable clinical assessments.
• Selecting, training, evaluating, and supervising AFC caregivers in conjunction with the care manager
• Reviewing the PCP Summary Form
• Monitoring the health status of all members to ensure that all needed AFC and/or GAFC is properly delivered
• Reporting changes in the health status of any member to the member's PCP
• Reviewing AFC caregiver logs at a minimum of every 30 days ( when appropriate)
• Conducting 2 to 3 on-site visits for AFC members with each member at the qualified setting
• Completing a nursing progress note corresponding with each on - site visit or encounter, or more often as the member's condition warrants
• Submitting semiannual health-status reports to the member's PCP
• Planning for and implementing discharges and transition from the AFC and/or GAFC program
• Conducting an orientation for each AFC caregiver before the AFC caregiver begins personal care; and providing ongoing training to AFC caregivers on health and aging
• Overseeing and managing all clinical charts
• Planning, implementation, and evaluation of AFC and/or Group Adult Foster Care setting
• Provision of case management
• Review and supervision of personal care services
• Review and clinical sign off on all personal care tasks (timesheets/task logs) when appropriate
• Visiting all clients on a regular basis; including but not limited to scheduling of client visits
• Communicates health status of the clients to the case manager and office management
• Follows all policies and procedures when working with a client
• Reports observations and functioning status of the clients in the internal charts
• Monitoring the health statistics of all participants to ensure that all AFC and/or GAFC is properly delivered.
• Completing an onsite progress note corresponding to each onsite visit or encounter.
• Performs any other additional duties that may be required by management at anytime.

Education , Experience and Licensure Requirements:

• Licensed by the Massachusetts Board of Registration in Nursing
• Must have at least two years of recent experience in the direct care of elders or adults with disabilities
• Excellent interpersonal and communication skills required
• Valid driver's license with proof of insurance required
• Bilingual in English and secondary language preferred
• Relevant experience, preferably in healthcare, home health care, case management, or sales preferred