Institute on Aging

Nurse

• Provide medical consultation to Care Management staff on diabetes management, medication management, wound care, and acute or chronic illnesses
• Participate in multidisciplinary team meetings and care conferences, recommending safe levels of care
• Ensure individuals transitioning from institutional settings have supports and services for safe community living
• Review discharge paperwork and consult with inpatient, outpatient, and primary care providers
• Provide ongoing training to CalAIM staff
• Complete assessments and documentation for waived services programs
• Ensure clinical documentation meets best-practice guidelines
• Analyze utilization patterns and help implement health-promotion interventions
• Collaborate with the CalAIM Leadership Team to improve program and process efficiencies
• Monitor the quantity and quality of services provided by involved providers
• Participate in Continuous Quality Improvement efforts
• Attend team and program meetings and contribute to communication and problem-solving
• Apply Institute on Aging regulatory and procedural requirements
• Attend continuing education and in-service training
• Perform other reasonably related responsibilities as assigned

Nurse Liaison

Community Health Worker

• Provide care coordination support with a preventative health focus to CalAIM clients in conjunction with the assigned Lead Care Manager
• Maintain regular contact with assigned clients to ensure referred services are being delivered
• Complete referrals and follow-up calls for connectivity to primary care, behavioral health, home health, durable medical equipment, and other health care services
• Conduct outreach and engagement with newly referred or authorized potential clients in homes, hospitals, nursing facilities, shelters, or on the street
• Educate clients about health and mental health care systems in a culturally appropriate manner
• Conduct home, acute hospital, and skilled nursing facility visits and escort clients to appointments as clinically indicated
• Assist the Lead Care Manager with documentation for Medi-Cal waiver participation
• Identify, arrange, and monitor community services based on knowledge of Medicare, Medi-Cal, and entitlement programs
• Establish professional relationships with clients and informal support networks
• Document client-related activity in progress notes within 24–48 hours as needed
• Maintain paperwork and consistent charting for continuity of care
• Communicate with community providers, physicians, and health and social service workers
• Provide relevant client-care and program-operation information while maintaining confidentiality
• Collaborate with the interdisciplinary team to support clients living in the community
• Participate in team and program meetings, activities, and problem-solving
• Use supervision appropriately and provide updates on client activity
• Apply the Institute on Aging’s regulatory and procedural requirements
• Attend continuing education and in-service training
• Perform other reasonably related responsibilities as assigned