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.
- 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.
- 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.