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RN Primary Nurse - Summit ElderCare - Leominster

Company: Fallon Community Health Plan
Location: Leominster
Posted on: November 23, 2020

Job Description:

RN Primary Nurse - Summit ElderCare - Leominster


Job ID: 6130Type: Full Time# of Openings: 1Category: NursingSummit ElderCare - Leominster


About Fallon Health
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation's top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
About Summit ElderCare:
Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon's PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities.
Position Summary:
Responsible for the effective management and delivery of direct nursing care to PACE participants in any setting utilizing nursing process and adhering to standards of nursing practice.


Primary job responsibilities:

  • Primary nurse not only has the responsibility for the participant, but the authority to advocate for the best care for the participant unique to their situation.
  • Fostering a relationship with the caregiver and participant.
  • Primary Nurse will take on a Leadership Role.
  • Effectively communicate with the healthcare team.
  • Assigns tasks and duties to the healthcare team; ensure the tasks are completed; responsible for their panel.
  • Develops an individualized plan of care.
  • Accountability for assessments, communicating needs and coordinating the care team.
  • Primary nurse develops the plan of care
  • Reviews and implements Provider's orders .
  • Conducts nursing assessments according to policy guidelines including physical, psychosocial, behavioral, and MDS-HC as indicated.
  • Involves participants and significant other(s) based on needs and abilities.
  • Delivers care to participants in any setting, including skilled services, based on individualized needs and according to age-appropriate nursing standards.
  • Provides for cultural and diverse needs of participants when providing care.
  • Monitors and evaluates therapeutic interventions.
  • Delegates and or accepts participants' care responsibilities to other members of the health care team, when appropriate.
  • Identifies emergency situations and initiates appropriate nursing orders/interventions.
  • Meets the needs of participants in a timely manner.
  • Participates in the interdisciplinary team (IDT) process and collaborates with IDT members to meet the needs of participants.
  • Consistently documents all aspects of participant care, including significant changes in health status, monthly nurses' notes and health care 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.
  • Initiates and completes falls, infection, grievance and incident reports
  • Participates in CMS calls when deemed necessary.
  • Active participant in the site specific committees.
  • Participates in the post IDT huddle and any other additional meetings
  • Any additional tasks deemed necessary by the Clinical Nurse Manager and or Site Director.
  • Assumes the role of the home care nurse, floor or triage nurse per the direction of the Clinical Nurse Manager or Site Director as appropriate.
  • Performs all duties in accordance with FCHP and Summit ElderCare policies and procedures.
  • Functions independently to administer medications and treatments as ordered by the provider.
  • Functions independently in the primary nurse role. Independent in performing a nursing assessment and executing the plan of care in all settings the participant maybe in.
  • Medication administration
  • Performing bladder scans, EKG, Point of Care, and glucometer testing Qualifications

    Education, Licenses, certification and experience requirements:

    Education: Graduate of an accredited school of nursing

    License: Current license as an RN in the state of Massachusetts

    Certification: CPR and Alzheimer's 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.Ability to use an electronic medical record.

    Other: Reliable Transportation Required

    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.

Keywords: Fallon Community Health Plan, Leominster , RN Primary Nurse - Summit ElderCare - Leominster, Healthcare , Leominster, Massachusetts

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