RN Care Manager

Job Summary: Provide direct and indirect nursing care to assigned patients. Works under the direct and indirect supervision of the Medical Director or designee but is independent in the application of advanced nursing knowledge and skills. Manages complex clinical situations for which he/she is responsible. Supervises both licensed and non-licensed personnel.

Duties/Responsibilities

Essential Job Functions:

Per PACE Regulation Section 460.104:

• As a member of the PACE Interdisciplinary team, the registered nurse is responsible for the following:
  • Regularly informing the interdisciplinary team of the medical, functional, and psychosocial condition of each participant
  • Remaining alert to pertinent input from other team members, participants, and caregivers
  • Documenting changes of a participant's condition in the participant's medical record consistent with documentation policies established by the medical director
• Each registered nurse is responsible for the following:
  • Involvement in a participant's medical situations
  • An initial comprehensive assessment including a comprehensive history and physical
  • Participation in the development of a plan of care
  • Periodic reassessments on a semi-annual basis or as a participant's condition dictates
    • Unscheduled reassessments take place either due to a change in participant status or at the request of the participant or designated representative.

- Participation in PACE-related committees

- Participation in the nurse on-call rotation for after-hours phone calls

Additional Essential Functions:

Care Management:

• Assess the health status and care needs of PACE participants through comprehensive health assessments.
• Develop individualized care plans in collaboration with the interdisciplinary team to address the physical, emotional, and social needs of each participant.
• Monitor and coordinate the delivery of nursing care services ensuring they align with the care plan and PACE program guidelines.
• Record, in the EHR, patient care delivered. Record observations related to impending or associated problems.
• Follow up on outside medical appointments and hospital stays.
• Provide health education and support to participants and their families to promote health maintenance and disease prevention.

Day Center Administration:

• Assists Center Manager in overseeing the day-to-day operations of the assigned PACE alternate care setting.
• Ensure compliance with regulatory requirements, PACE program standards, and safety protocols at the day center.

Participant Engagement and Support:

• Foster strong relationships with participants and their families, addressing their concerns, and ensuring their needs are met promptly.
• Act as a point of contact for participant-related issues and serve as an advocate for their overall well-being.
• Encourage participation in day center activities and engage participants in the planning and development of programs.

Clinical Documentation and Reporting:

• Maintain accurate and up-to-date clinical documentation, including care plans, progress notes, and other required reports.
• Provide regular updates on participant health status and care plans during interdisciplinary team meetings.

Quality Assurance and Compliance:

• Participate in quality improvement initiatives, identifying opportunities to enhance the delivery of care and services.
• Ensure compliance with regulatory requirements, PACE program standards, and relevant policies and procedures.

Staff Development and Training:

• Provide guidance and training to day center staff, promoting a supportive and professional work environment.

Collaboration and Communication:

• Collaborate with the broader PACE program team, including healthcare providers, social workers, and other care managers, to facilitate coordinated care for participants.
• Communicate effectively with participants, families, and external stakeholders, building positive relationships and addressing concerns.

Physical Requirements: Physical Demand: Moderate physical activity performing somewhat strenuous daily activities of a primary administrative nature.

1. Stand less than 33% of time.
2. Walk between 33% to 66% of time.
3. Use of hand to finger, handle or feel required over 66% of time.
4. Use of hands and arms to reach over 66% of time.
5. Climb (stairs) between 33% and 66% of time.
6. Full ability to talk and hear.
7. Correctable vision required.
8. Able to lift/carry up to 30lbs.

Minimum Educational and General Qualifications:

Must be a graduate of an accredited school of nursing and have a current RN license. Must have practiced nursing in the last three years. Position requires eighteen months RN experience with at least twelve of those months in geriatric practice area. Must present credentials which demonstrate ability to meet performance criteria for the position and possess knowledge and skills necessary to treat geriatrics patients.