RN- Case Manager

Under the direction of the Center Manager, the RN-Case Manager provides initial and routine clinical nursing assessment visits and home safety evaluations to PACE participants and families utilizing all elements of the nursing process and in compliance with applicable laws, regulations, and organizational policies. The RN-Case Manager primarily provides nursing visits in the participant’s home in the community but can routinely visit participants in the PACE center, hospitals, nursing homes, and another alternate setting as deemed necessary for care coordination consistent with the PACE model of care. The RN-Case Manager is a core interdisciplinary team (IDT) member who is assigned to a PACE participant in compliance with CMS PACE regulatory requirements.

KEY RESPONSIBILITIES

• Carries out the organization’s mission, philosophy, goals, and objectives within guidelines of policy and position function.
• Interprets and implements the organization’s philosophy to staff and members of the community.
• Provides pre- and post-enrollment home safety assessments and makes recommendations to the IDT regarding maintenance of participant safety in the least restrictive environment possible.
• Collaborates with all members of the IDT in developing a comprehensive non-skilled home care plan based on participant-specific needs, physician orders, participants’ specific parameters, and identified goals that are respectful of participant, family, community, and organizational resources.
• In conjunction with the Home Care/Clinic Coordinator, provide skilled nursing services to participants in their homes as needed.
• Recognizes and utilizes additional opportunities for health counseling/education with patients, families, and other caregivers and provides them with information that will facilitate decisions regarding the promotion, maintenance, and restoration of health.
• Schedules, coordinates, and oversees all non-skilled home health care to be administered to participants in their homes.
• Supervises personal care assistants under his or her direction.
• Delegates responsibility appropriately and supervises ancillary personnel in a manner that will ensure quality care and compliance with the care plan.
• Evaluates and promotes a safe environment for the patient and complies with National Patient Safety Goals.
• Completes, maintains, and submits all required documentation that is timely (in compliance with organizational policy), accurate, and relevant.
• Performs care coordination as part of their nursing visits to PACE participants across all settings of care. Collaborative care coordination to include internal (e.g., other IDT members) and/or external health care professionals (e.g., MD specialists, SNF staff, hospital staff) in a manner that assures care plan coordination as well as continuity of care.
• Assumes responsibility for personal growth and development; maintains and upgrades professional knowledge and practice skills through attendance/participation in continuing and in-service education programs.
• Meets organizational productivity guidelines.
• As requested, participates in, and assists with staff and student orientation and development; participates in internal and external committee activities; and represents the organization in the community.
• Participates in performance improvement activities, as required.
• Participates in evaluating overall position performance, goal setting and achievement, and performance improvement plan.
• Provides cross coverage for the Home Care/Clinic Coordinator
• Participates in on-call rotation for after-hours participant needs.
• Other duties as assigned.

EDUCATION & EXPERIENCE

Experience:

• Degree from an accredited school of nursing required; BSN preferred.
• Minimum of one (1) year general clinical experience in a certified home health agency, acute care, medical surgical, and/or critical care environment, or Nursing Home experience required. Clinical experience must be within one (1) year from date of hire or transfer, required.
• Current American Heart Association BLS required
• Customer Service experience is required.
• Minimum of one (1) year of experience working with the elderly.
• Current valid driver’s license, valid current insurance and reliable transportation required.

The following are required skills at time of hire or transfer and must demonstrate recent verifiable experience (within one [1] year) to independently perform:

• IV Therapy
• Phlebotomy / Venipuncture
• Basic EKG interpretation
• Basic Life Support certified by the American Heart Association or American Red Cross

License: Current active and unrestricted license and registration in the State required as a Registered Nurse.

Job Type: Full-time

Schedule:

• Day shift
• Monday to Friday

Experience:

• working with elderly : 1 year (Required)
• acute care, med surg, critical care, or Nursing Home : 1 year (Required)