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Director of Nursing & Community Care

The Director of Nursing and Community Care is a vital leadership team member responsible for administrating, managing, and overseeing all nursing-related, intensive case management, care transition activities, and initial assessment activities. Reporting to the Senior Director, the Director of Nursing and Community Care acts as the clinical leader for the Home and Community Based Services (HCBS) team of Somerville Cambridge Elder Services. This position is responsible for supporting the management team of a variety of departments. The role is intended to operate as the clinical half of a dyad, with a counterpart supporting these teams from a care management and community service perspective.

The Director of Nursing and Community Care will inform clinical practices, support development, tracking and reporting on metrics such as Key Performance Indicators (KPI’s) and contribute to the overall clinical strategy of the HCBS teams. This individual will also be comfortable operating closely with member-facing staff and managers to support department and agency initiatives and track to quality and performance management. In addition to providing direct supervision to nurses, case managers, and administrative support staff, this position may supervise care transitions and intensive case management staff. Additionally, as part of HCBS’s leadership team, the Director of Nursing and Community Care provides clinical expertise and functions as an agency consultant and trainer regarding mental and physical health issues of aging, social determinants of health, and care coordination.

Job Responsibilities and Performance Standards:

  • Under the direct supervision of the HCBS Director, is responsible for the administration, management, and clinical oversight of HCBS and Long-Term Services and Supports (LTSS) departments and activities in accordance with agency and program regulatory, eligibility, contract, and documentation requirements.
  • Serves as the primary contact for EOEA and MassHealth’s Office of Long-Term Services and Supports (LTSS) for these programs/activities.
  • Provides direct supervision, performance evaluations, training, support, and direction to department staff. Ensures that direct reports’ performance meets expectations and satisfies the requirements of their positions.
  • Provides clinical consultation, risk assessments, safety planning, and participation in complex discharges/care transitions for HCBS consumers as needed. Works with external stakeholders to support care transitions and promote safe discharge planning for medically and behaviorally complex community-based clients, referrals, and Skilled Nursing Facility (SNF) residents.
  • Participates in interdisciplinary case conferences with the HCBS departments and Protective Services staff according to EOEA guidelines or as needed. Provides clinical consultation on complex caregiving cases, specifically caring for persons with dementia and/or Alzheimer’s disease.
  • Identifies opportunities to enhance programs and services to support caregivers and clients with complex physical and/or behavioral health needs, coordination of care activities, and barriers to discharges, including those residing in skilled nursing facilities.
  • Participates in EOEA, MassHealth, and other meetings requested by the HCBS Senior Director; communicates meeting updates to SCES leadership and applicable staff. Implements such changes or updates and conducts project management activities based on meeting outcomes and/or new program initiatives.
  • Works with SCES leadership to identify and develop policy and procedures, workflows, and health-related training for staff. Trains new staff on items such as identifying fall risk, home safety assessments, and common medication interactions. Ensures that all training requirements are met by nursing staff per the ASAP contract.
  • Fosters continued relationships with area SNFs, hospitals, vendors, and healthcare providers to educate them on SCES department programs including referral processes and requirements. Monitors and assigns referrals received including performing quality checks.
  • Collaborates cross-departmentally on community outreach initiatives to increase department referrals, agency brand awareness, and relationship building, along with providing consultation and oversight to assist with triaging and transitions of care for acute/complex cases and referrals received for high-risk individuals.
  • Creates marketing and instructional materials on eligibility, referral processes, and requirements for SCES programs and services.
  • Participates in home visits, discharge planning meetings, family meetings, and/or care transition activities as needed.
  • Evaluates and analyzes data and reports to identify internal and external opportunities for improvement. Ensures clinical eligibility requirements, documentation, paperwork, and service deliveries are met and comply with initial and ongoing program enrollment/activities and client monitoring.
  • Responsible for all reporting mandates for community and facility-placed residents, including DPH, Ombudsman, Protective Services, and EOEA incident reporting. Participates in Fair Hearings and Appeals processes and decision-making.
  • Performs other duties as assigned, including those in SCES’ ASAP contract agreement.

Professional Standards and Conduct:

Collaborative and Responsive: Regularly communicates, follows up, and uses a team-driven approach. Responds thoughtfully and promptly to agency and client needs, requests, and inquiries and identifies and builds partnerships with key internal and external stakeholders. Has excellent organizational and time management skills to meet various deadlines, ensuring closed-loop communication, multi-tasking, and flexibility. Regularly collaborates cross-departmentally to serve our clients best and support HCBS department staff.

Communication: Strong written and verbal communication skills, focusing on clear and concise communications with internal and external stakeholders, providers, and departmental staff. Comfortable with boundary setting, de-escalation, and clarifying roles and expectations to vendors, providers, clients, and caregivers in a respectful and courteous manner. Excellent public speaking and presentation skills.

Analytical: Strong attention to detail. Able to apply critical thinking, coordination, and problem-solving skills to ensure program compliance requirements are met and clients receive high-quality care. Is proactive in identifying areas for improvement and implementing training and processes to support staff around clinical needs and ongoing skill development and compliance efforts. Reviews and interprets directives and requirements from stakeholders such as EOEA and MassHealth and follows up in a proactive, solutions-focused manner. Data oriented and comfortable engaging with quantitative information, including identifying informational gaps and generating planning to bridge such gaps. Able to interpret data to track performance including KPIs and quality metrics.

Attendance and Punctuality: Dependable, punctual, showing flexibility when needed. Attends meetings as needed and is fully present and participates during those meetings.

Commitment: Embodies SCES’s core values and shows great integrity, accountability, and professionalism. Aids in furthering SCES’s mission and commitment to an inclusive environment.

Qualifications:

  • Graduation from a School of Nursing accredited by the National League for Nursing required; B.S.N. required. M.S.N preferred, Valid license as a registered nurse in the Commonwealth of Massachusetts is required.
  • At least six (6) years of full-time or equivalent experience as a registered nurse in a community setting is
  • At least four (4) years of supervisory, administrative, or managerial experience is Additional experience beyond four years is strongly preferred. Clinical supervision experience is required.
  • Previous experience with the older adult population, mental health, care coordination, and/or community health settings required. Aging Services Access Point (ASAP) experience is strongly preferred. Knowledge of the State Home Care system, MassHealth LTSS programs, and/or community resources is strongly preferred.
  • Must be knowledgeable and comfortable using Adobe and MS Word, Excel, PowerPoint, SharePoint, and other Microsoft 365 platforms. Experience with Wellsky is strongly preferred.
  • Experience with compliance monitoring and tracking is required. This may include but is not limited to quality assurance, reporting, audits, and training. Ability to interpret regulatory and business processes and develop and implement policies and procedures
  • Must receive certification in Habilitation Therapy within the first 6 months of hire.
  • Valid driver’s license required. Must be able to travel to consumers’ homes, area hospitals, and nursing homes via public transportation or by car.
  • Meets both CORI/SORI and public health screening requirements.

Physical Environment

  • Physical surroundings are comfortable with minimal exposure to injury or hazards.

Social/Psychological Conditions

  • Occasional stress due to periodic or cyclical workload pressures and deadlines. Some interruptions involved.
  • Frequently sits throughout the day.
  • Periodic eye strain and light ear strain.

Physical Effort

  • Frequently sits, stands, walks, bends, reaches, and stoops throughout the day.
  • Frequently lifts, pulls, pushes, and carries up to 20 lbs.
  • Periodic eye strain and light ear strain.