Under general supervision by the Supervisor, Nursing and oversight by the PACE Physicians, the Nurse (RN) Case Manager/Care Coordination Team Leaderhas the responsibility to case manage all PACE participants who are in the ambulatory setting.
Responsibilities Develop the nursing component in the plan of care for patients, specifying short- term nursing goals in each individualized plan of care. Responsible for Initial Assessment for potential new enrollees (Home-Visits to support environmental and physical assessments). Responsible for ensuring coordination and completion of reassessments every 6 months 1:1 at Center and/or Home for assigned case load. Responsible for the allocating in home supportive caregiver hours based on the Nurse and the IDT Assessment. Activities of Daily Living and Instrumental Activities of Activities Living (ADL’s and IADL’s). Acts as a liaison between the Participants and the Interdisciplinary Team Members. Acts as a liaison between homecare services and PACE center services to ensure adequate coordination and effectiveness of program delivery. Provides P/P/C, Family, and Caregiver Individual Health Education on Disease Process. Elements of the health education process include verbal and written hand-outs for their reference. Documents any activities encountered between the participant, families, caregivers, contracted providers, hospitals, SNF, and other facilities working together with PACE for participant’s well being. Troubleshoots issues with RN Supervisor and providers. Responds to medical emergencies and will take the lead in management of the situation as indicated. Functions as Patient Advocate, ensuring that patient concerns are resolved or addressed expeditiously. Screen and triage “walk-in” and “call-in” patients as needed. Ensures the implementation and compliance of patient care as per provider’s order. Collaborates and Supports and reports infection-control policies and procedures as necessary for PACE. Document all nursing care on the day the service is rendered while adherening to PACE documentation guidelines and all PACE policies and procedures related to medical care provision. Monitor, administer, and record ordered medications. Participates as an active member of the INTER-disciplinary team (IDT) to assess the nursing need of the patient. Collaborates and coordinates to ensure efficient operations in PACE, or clinical setting, i.e. staffing. Maintains acceptable standards of nursing care, based on regulatory requirements, as well as JCAHO and AltaMed standards. Assists with preparing for various quality, county, state, and federal audits. Assumes the role of Supervisor, Nursing in his/her absence and assists in completing subordinate’s performance evaluations as/if needed. Performs other related duties as assigned.
Qualifications Current valid License as a Registered Nurse through the California Board of Registered Nursing. A minimum of one year experience in Geriatric Nursing required. A minimum of one year experience preferred in managed care setting, preferably in utilization or case management in ambulatory or inpatient setting. CPR/First Aid Certificate required. Bilingual English and Spanish preferred.