Centers Plan for Healthy Living

Assessment Nurse - Field

Job Locations US-NY-Staten Island
Posted Date 2 weeks ago(3/12/2018 11:32 AM)
# of Openings




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 The Assessment Nurse, works in collaboration with the Care Management team and is responsible for assessing a member’s eligibility for the Centers Plan for Health Living’s  (CPHL all LOB programs.  The Assessment Nurse will conduct a face-to-face comprehensive assessment utilizing NYSDOH approved assessment tool (UASNY) and risk acuity visits with a member in his/her place of residence. The Assessment Nurse is a member of the interdisciplinary care team (IDT).


The members interview, assessment and documentation process are a core component of CPHL care management delivery model. Interdisciplinary Care Team (IDT) works together to evaluate, assess and develop a comprehensive, person-centered plan of care that is based on the responses to the assessment.  The components of the assessment and plan of care are structured to ensure quality and consistency that support improved member outcomes and seamless care coordination amongst the members of IDT.




Included but not limited to:

  • Performs comprehensive UASNY assessments including Functional and mental supplements as triggered of a member making appropriate determination for a member’s eligibility into the program (s)
  • Determines level of member risk acuity based on the comprehensive assessment
  • Performs face-to-face Initial Care Visit (ICV) and ongoing visits based on the member acuity level
  • Identifies medical, functional, psychosocial, behavioral health, cultural and linguistic needs of the member and discusses member/family active engagement in development of person-centered service and care plans and decision-making.
  • Effectively completes the required assessment form (UASNY) and other Centers Plan for Healthy Living (CPHL) necessary documents within the required timeframes and in accordance with CHPL established policies and procedures and State and Federal guidelines and regulations.
  • Participates in the IDT.Effectively collaborates with the Care Managers to establish continuity of care and interventions as they relate to members’ needs addressing any urgent needs of a member
  • Recognizes quality of care issues, escalates the issues appropriately to the care manager, and discusses issues at the IDT.Complies with all CPHL’s standards for documentation.
  • Maintains member confidentiality and compliance with HIPPA requirements
  • Participates in regularly scheduled and other staff meetings as requested
  • Participates in quality improvement initiatives
  • Other duties as assigned



Education and Experience:


Type of Experience  


 Knowledge of current community health practices for the frail adult population, behavioral health and cognitively impaired seniors and disabled including knowledge of physical health, aging and loss, appropriate support services in the community, frequently used medications and their potential negative side-effects, depression, challenging behaviors, Alzheimer’s disease and other disease related dementias, issues related to accessing and using DMEs.

Understanding of and sensitivity to cultural differences and needs of the community are essential. Must be adept at operating within a diverse and multi-cultural work environment and community of members such as Spanish, Chinese, Russian, Creole and Korean




Graduate of a 2- 4 year accredited nursing program;

Active and unrestricted NYS RN license

Strong written and verbal communication skills.

Must possess a valid driver’s license, motor vehicle insurance and access to a motor vehicle, or access to reliable public transportation within the appropriate service area

Ability to travel within assigned area

Proficient in the use of Microsoft office Suite tools

Professional Liability Insurance



Bachelor of Science in Nursing or advanced degree

Minimum 2 years Care Management experience with the geriatric population and /or minimum of 2-4 years clinical nursing experience in home health care or MLTC






Experience providing care in the home setting

Experience working within a managed care environment


Specific Technical Skills

Required:   Computer proficiency







# Direct Reports:         0                     



Physical Requirements:

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


  • Must be able to operate office equipment including a computer and phones
  • Able to communicate both in person and by phone
  • Must be able to travel as needed


The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification.  They should not be construed as an exhaustive list of all responsibilities, duties and skills required.















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