Case Manager - RN

The Case Manager PACE Works collaboratively with all members of the health care team and the participant/family to ensure coordination of participant care and resource utilization.  The Case Manager participates in the assessment of participants including physical and psycho-social factors in order to plan for individualized continuum of care needs and ensures the implementation of the care plan.  Provide direct and indirect nursing care to assigned patients.  Works under the direct and indirect supervision of the Clinic Manager or designee but is independent in the application of advanced nursing knowledge and skills.  Manages complex clinical situations for which he/she is responsible. Additionally provides basic tele-health on-call rotation, generally 1 week per month.

Care Management

1. Care provided conforms to accepted practice standards; provides correct treatments/procedures and other care as prescribed and according to participant care standards; demonstrates understanding of age-related characteristics and needs of participants served.
2. Explains nursing procedures in appropriate forms; identifies emergency situations and independently initiates advanced therapy; acts as coordinator of participant care with other health care personnel and evaluates participant care measures instituted; understands and demonstrates respect for participant rights and utilizes established mechanisms for management of ethical issues in participant care.
3. Responsible for the oversight of all care components of each Participant assigned. Coordinates the care of the Participant. Responsible for follow-up of acute illnesses and problems. Has knowledge of the Participant's on-going status at all times.
4. Responsible for appointment and referral scheduling, chart management.

Assessments

1. Collects participant data and completes required forms with appropriate responses according to PACE standards; identifies participants overt problems/needs and sets priorities; identifies problems requiring further referral and/or follow-up; interprets and records latest diagnostic results.
2. Performs advanced nursing assessment using critical thinking skills. Performs assessments timely as required.
3. Using assessment skills, completes the required MDS-HC timely as required on initial assessment and yearly as required

Leadership

1. Demonstrates active participation in Quality Assurance Performance Improvement processes.
2. Using nursing process, delegates nursing care to appropriate personnel; integrates cost effective measures into nursing practice; recognizes unit problems and takes responsibility for documenting same.
3. Complies with policies addressing safe working conditions; monitors unsafe working conditions; recognizes inappropriate and/or ineffective participant care management, resolves issue/problem and completes written reports.

Clinical Skills

1. Administers prescribed medications/treatments, including IVs in accordance with nursing standards.
2. Performs phlebotomy and EKGs if applicable.
3. Performs wound care as ordered and performs weekly assessments as required by standards with accurate documentation in EMR.

Interdisciplinary Team

1. Develops a plan of care based on nursing process, with complete understanding of measurable goals with outcome-based planning and incorporates the plans of other disciplines and continuing care needs according to CMS guidelines; includes the participant/family in developing or revising the plan of care; makes referrals to interdisciplinary support services.
2. Communicates participant changes to team members.
3. Records participant care delivered as planned and any variation, with appropriate rationale; makes and records observations related to impending or associated problems.

Experience: Experience with the frail/elderly in accordance with CMS regulations for PACE programs.

Education: Graduate of accredited school of nursing

Training: Possess knowledge and skills necessary to treat geriatrics participants

Special Skills: IV expertise and ability to multi-task and triage clinical situations. Must have in-depth assessment skills for the geriatric population.

Licensure: Current Louisiana State license as RN; BLS