SUMMARY: The RN Care Manager is responsible for assessing the care needs of participants, provides nursing and healthcare interventions, and evaluates outcomes of care of participants on an ongoing basis. In collaboration with the interdisciplinary team (IDT), develops plans of care to meet participants’ needs. Delegates tasks to clinic, center, and homecare aides according to participant needs and care plans. Collaborates and communicates with the primary care provider, clinic staff, and other members of the IDT. Provides care to participants in the clinic, center, and participant homes as needed.

ESSESNTIAL DUTIES AND RESPONSIBILITIES:

• Provide high quality clinical care and serves as a member of the PACE interdisciplinary team (IDT).
• Provide nursing care in the center, clinic, contracted facilities, and participants’ homes according to each participant’s plan of care. (
• Participate in 24/7 “on-call” process for triage of participants and their needs.
• Assess, plan, and coordinate participants’ home care services. Provide input to the IDT in developing home care plan interventions. The nursing care needs of the participant shall be assessed only by a registered professional nurse.
• Monitor participants’ acute and chronic care needs in all settings. Provide coordination and direct care as indicated to promote continued care in the community or promote optimal institutional care (Assisted Living, Nursing Home, Hospital, etc.) as needed.
• Ensure timely follow-up by providers on specialist visits and will assist with obtaining specialist reports, facility documentation, and labs if needed.
• Reconcile facility MARs for your assigned panel of participants monthly to ensure accuracy and medication adherence, notify provider of any discrepancies.
• Notify participants of normal test results.
• Complete timely and accurate nursing assessments in accordance with policies and regulatory requirements.
• Implement nursing-related care plan interventions.
• Teach participants, caregivers and families about self-care, medications, healthy lifestyles, infection control and safety to promote optimal health and safety.
• Review and revises goals and approaches to participants’ care in coordination with participant, family, caregiver and interdisciplinary team.
• Works collaboratively with the interdisciplinary team (IDT) to develop and implement comprehensive plans of care for participants.
• Develop and maintain positive relationships and communication with co-workers, participants and their families/significant others, and members of the community.
• Participate in all interdisciplinary team meetings.
• Assist the interdisciplinary team members in understanding the significant nursing, self-care and functional needs related to the participant’s health problems.
• Supports OT as aback up to performing the duties of Home Care Coordinator on the IDT as needed/when assigned. May perform the duties of other IDT members based on professional licensing, competencies, and experience as needed.
• Actively participates in utilization review meetings and quality improvement projects / meetings.
• Evaluates the competence of CNAs and Home Care Aides and delegates tasks and duties to them as indicated.
• Participates in family meetings, staff meetings, in-service and training and orientation programs as required.
• Follows all PACE Program Policies and Procedures and Occupational Safety and Health Administration (OSHA) safety guidelines.
• Protects privacy and maintains confidentiality of all company procedures and information about employees, participants and families.
• Practices standard precautions and follows PACE Program Infection Control protocols.
• Performs other duties as required or requested.

EXPERIENCE, EDUCATION AND CERTIFICATIONS:

• Bachelor of Science in Nursing Degree preferred.
• State RN License required
• BLS required (have within90 days of employment).
• 1 year of experience working with a frail or elderly population preferred. If this is not present, training will be provided upon hiring (If applicable for the role).  
• Experience in home care, long-term care and /or managed care preferred.
• 1 year experience providing care as an RN required.