TSAO Foundation – Care Manager, Nurse

To be responsible as the Care Manager to assess, facilitate and advocate for the clients' interest, to meet operational targets of the Foundation and the funding authorities.

Key Responsibilities

• Determine suitability of client referrals as a team through initial screening in accordance with Foundation guidelines and requirements of funding bodies
• Conduct full assessment, as a component of team assessment in the areas of medical, nursing, social, financial and psychological etc and ensure assessments are carried out as required
• Identify problems related to illness and decline in functional, cognitive abilities and advocate early medical attention for client through appropriate intervention or referral
• Facilitate the use of internal and external resources through appropriate linking of services to serve the basic support needs of the clients and families
• Develop comprehensive client care plans and carry out regular evaluation, ensuring recommended services are in place to meet the needs of the clients, families and caregivers
• Provide health education to the clients and families to reduce medical complication and accident prevention, and monitor medication management and compliance, nutrition, diet etc.
• Participate in regular client review discussions with team members to evaluate efficacy and currency of care plans, and recommend modification as needed
• Liaise with external agencies from government, social services and medical establishments to establish an effective network of care for the continuing care of the clients, particularly in respect of a good hospital discharge plan
• Conduct termination reviews when required and write the relevant reports and referrals to facilitate the clients' discharge to another service
• Ensure CM activities meet regulatory requirements, and ensure accurate and timely documentation and submissions of client reports
• Participate in continuous quality improvement projects
• Represent the Foundation in presentation to external parties such as students on clinical attachments
• Participate and lead where appropriate, in activities or outreach projects - internal or joint, that promote the Foundation's cause and mission

Qualifications

• Singapore Nursing Board registered Nurse with minimum 3 years working experience
• Professional certification / specialist diploma / advance diploma on gerontological nursing is preferred
• Courses on care management is preferred
• Working experience in case management / care coordination will be an added advantage
• Excellent clinical knowledge and skill
• Good communication skills in both spoken and written English
• Penchant for working with older people
• Able to communicate in Mandarin and local dialects to communicate with the senior citizens.
• IT proficient