Nurse-AAoA

Overview

Announcement #  |
Issue Date: 10-08-25 |
Closing Date: 10-29-25

Nurse
Area Agency on Aging

Department of Human Services

Hourly Wage: $36.11-$40.64/Regular/Full-Time

• Provides support for clients, including coordinating an array of services designed to improve the health of high needs, high-risk clients. Care coordination responsibilities include assessment, care planning, monitoring of client status, and implementation and coordination of services.
• Support to clients for effective care transitions, improved self-management skills, and enhanced client-provider communication.
• Facilitate interdisciplinary consultation, collaboration, and care continuity across care settings.
• Provide clients, providers, and case managers with health-related assessment consultation to enhance the development and implementation of the client s plan of care for TXIX and Home & Community Case Management; perform case management duties and carry a caseload.
• This position is not a direct care provider of intermittent or emergency nursing care, skills, or services requiring physicians  orders and supervision.
• Coordinate follow-up activities and referrals with other programs (e.g., Family Caregiver Support Program and HCS Medicaid Case Management).
• Provide health-related assessment and consultation in the development of the plan of care through the CARE Tool to case managers.
• Complete Skin Care Protocol based on the ALTSA Long Term Care Manual.
• Identify and address barriers to accessing health care and social services.
• Engage clients in care coordination activities to promote improved utilization of health care services, including maintenance of a patient-centered, goal-oriented Health Action Plan.
• Assess activation level for self-care using the Patient Activation Measure (PAM).
• Provide evidence-based health assessments and screenings (e.g., BMI, PHQ-9, Katz ADL, PSC-17, GAD-7, AUDIT or DAST).
• Provide transition support services that coach the client in four pillars: medication self-management, use of a patient-centered health record, primary care and specialist follow-up, and knowledge of red flags for their condition and response.
• Work with supervisors and other health care providers, hospital discharge planners, skilled nursing facility staff, and health home staff to implement services and analyze disposition of cases.
• Perform facility visits, home visits, and follow-up calls to develop coaching relationships and empower clients in discharge planning.
• Coordinate and communicate post-discharge status with involved health care providers (primary care, mental health, specialty care, pharmacy).
• Provide referrals and advocacy for clients and caregivers to community-based services and supports (e.g., family caregiver programs, nutrition programs, in-home care, case management).
• Provide teaching about self-management of chronic health conditions and resource links to ongoing chronic disease self-management support services.
• Develop and maintain complete and concise client files in compliance with policy for documentation of activities and program requirements.
• Maintain all required documentation related to services and meet monthly deadlines.
• Participate in staff meetings, public education, and provider training sessions as appropriate.
• Develop and maintain relationships with community agencies and organizations that can provide resource support to the program or individuals.
• Prepare correspondence, memos, and client-related written materials as appropriate.
• Participate in continuing education and training programs.
• Work collaboratively with multi-disciplinary teams involving nurses, case managers, and case aides.
• Attend required meetings and trainings.

• Knowledge of the long-term care system and services, aging and disability issues, and case management.
• Knowledge of local in-home and community options and resources for the elderly and adults with disabilities and their caregivers.
• Knowledge of pharmaceuticals and their desired effects or complications.
• Knowledge of direct functional assessment, service planning, and implementation experience.
• Computer and software skills including Word, Excel and…