Registered Nurse Case Manager

Description

Who We Are

Are you interested in working for an organization whose mission is to enable frail, underserved, and multicultural senior communities to live independently at home and in their communities, for as long as possible?

Fresno Program of All-Inclusive Care for the Elderly (PACE) is dedicated to providing its participants with comprehensive health and social supports that are proven to effectively manage chronic conditions and to reduce the risk for premature institutionalization. PACE staff are leaders in the “aging in place” industry and we have had the honor of serving Fresno, Bakersfield and Orange County seniors and their families/caregivers.

Job Summary

The Registered Nurse Case Manager (RN CM) is responsible for assessing, coordinating, monitoring, and providing health care services and case management for an assigned panel of Innovative Integrated Health participants. 

Essential Job Functions

• Assessing participants physical and mental wellness, needs, preferences and abilities, and developing plans to improve

• Conducting Home Care Nursing assessments to determine the nursing, personal care and equipment needs in the home, 

        preferences and goals of the participants and actively participating in Interdisciplinary Team (IDT) meetings to develop 

        participant care plans.

• Delivering and documenting home care nursing interventions as agreed upon in the participants’ care plans including but 

        not limited to maintaining a healthy and safe environment, promptly and accurately responding to physician orders, and 

        correctly administering medications and performing ordered tests and treatments.

• Instructing the participant, family and caregivers regarding the disease process, self-care techniques, and prevention 

        strategies.

• Providing on-site supervision and instruction to Personal Care Assistants and Licensed Vocational Nurse (LVN) assigned to 

        participants’ homes at least as frequently as specified in the Home Health Agency regulations and more often if necessary.

• Recording participants’ progress, charting referrals, and scheduling home visits

• Tracking and monitoring home care hours and scheduling.

• Remaining alert to pertinent input from other team members, participants, and caregivers and updating IDT promptly of any 

        changes in participants’ condition or medical status.

• Following up with participants who are admitted into the hospital and/or Skilled Nursing Facility (SNF) to ensure they are 

       satisfied with services and are seen by their Primary Care Physician (PCP) upon discharge.

• Working with the PACE Providers and other members of the IDT to manage smooth care transitions between settings 

        (hospitals, skilled nursing facilities, home, etc.).

• In coordination with the Marketing Team, supporting enrollment of prospective participants into the program.

• Participating in end-of-life care coordination and support.

• Listening to participants' concerns and providing counseling or intervention as required

• Evaluating participants’ progress periodically and making adjustments as needed

• Responsible for completion of initial medical history, physical exam, and functional nursing assessments of each new 

        participant and semi-annual, annual, and unscheduled assessments; communicate changes in participant health or 

        functional status to the interdisciplinary team members and participate in development of the plan of care and coordination 

        of care delivery.

• Involved in the development and implementation of Quality Improvement activities; evaluate overall effectiveness of the 

        center, implementing change and quality improvement as needed. 

• Facilitate integration of new participants into the Innovative Integrated Health care delivery system, including medication, 

        immunizations, routine monitoring of chronic problems, and nursing care plan development.

• Will provide phlebotomy services in the participants home and/or clinic as ordered by the PCP.

• Coordinate participant care with outside contracted service providers, including hospitals, nursing facilities, assisted living 

        facilities, lab, oxygen, etc.

• Communicate with weekend and after-hours on-call staff, following up on issues as necessary.

• Review participant medical records to ensure timely and accurate clinic staff documentation.

• Supervise clinic staff’s administration of prescribed medications and treatments in accordance with nursing standards.

• Act as liaison with primary care provider in the event of an episodic illness; assist in coordinating se