RN Nurse Case Manager

POSITION SUMMARY: As a member of the Interdisciplinary Care Team, the Nurse Case Manager is responsible for the coordination and implementation of health care services for each consumer residing in Elwyn's community residential sites. The nurse provides clinical and consultative services and educates the team about consumer-specific needs. The nurse also liaisons with external providers to facilitate care coordination and ensures that established standards of care are met. The Registered Nurse practices within the scope of Pennsylvania's Nurse Practice Act and in accordance with Elwyn's policies and procedures and those of Elwyn's regulatory agencies. DUTIES AND RESPONSIBILITIES: * Review ongoing medical, dental, and psychiatric treatment with the treatment team to ensure recommendations are addressed in a timely manner * Assist in identifying health care needs and provide site staff with consumer-specific training that focuses on general health conditions, treatments, and interventions specific to each individual's health needs and consistent with standards of care * Review all Medical Appointment Summaries, lab data, and diagnostic test results with the Treatment Team * Provide continuity of care through timely follow up with physicians and other health care providers to ensure that agency and licensure requirements are met * Monitor consumers' weights and vital signs on a monthly basis and more frequently as needed; identify changes from baseline and report abnormal findings to the Primary Care Physician * Summarize Medical Appointment Summaries, telephone contacts, and ongoing health care follow up in the nursing progress note * Complete Falls Assessment for identified 'at risk clients' as per Elwyn Policy * Monitor consumer immunization status and ensure that each consumer remains up to date and current (as per Pennsylvania (PA) State regulatory guidelines) * Monitor consumers for potential safety risks and the need for adaptive equipment, monitor all adaptive equipment to ensure that it remains in good working order and facilitate repair/replacement when equipment issues are identified * Complete a monthly review of medication boxes and Medications Administration Records for each site in collaboration with the Program Staff to ensure accuracy/no expirations of medications; provide a written report summarizing any issues or discrepancies to the Director of Operations of CRS, Program Director, Quality Improvement Specialist, and Senior (Sr.) Director of Community Nursing for PA and New Jersey (NJ) * Complete a comprehensive on site physical assessment of each residence on a monthly basis to validate that privacy, safety, infection control and general standards are met; document results of the assessment in the electronic health record, and provide a written report summarizing any issues or discrepancies to the Director of Operations of CRS, Program Director, Quality Improvement Specialist, and Sr. Director of Community Nursing for PA and NJ * Provide coordination of clinical services between Elwyn's CRS Program and hospitals, physicians, pharmacies, and other community-based providers and services to ensure quality of care, confirm coordination of resources/services by email with providers * When a consumer is admitted into a hospital, skilled nursing facility, or rehabilitation center: * Collaborate with the facility's staff to ensure appropriate care and maintain active involvement in discharge planning throughout the consumer's stay with on-site visits as necessary * Initiate discharge planning on the day of admission to the facility, and schedule at minimum of biweekly meetings with the facility staff to assure a smooth transition at discharge * Oversee the consumer's transition back to Elwyn by reviewing discharge recommendations, ensuring that medication/equipment is available, and providing staff training related to ongoing care and treatment needs * Monitor ongoing medical/safety needs during the transition back to Elwyn, providing support as needed to ensure a smooth transition and placement at the facility * Obtain and review all reports from all inpatient stays, Emergency Department visits, diagnostic procedures, and specialty appointments coordinating follow up health care needs as indicated * Provide nursing-on-call coverage as required, completing on call progress notes, documenting in the Electronic Health Record and forwarding to administration and the treatment team notification to ensure timely communication * Complete incident reports and Emergency Department/Hospitalization reports for Quality Improvement and Home and Community Services Information System/Enterprise Incident Management (HCSIS/EIM) system reporting purposes * Participate in meetings, committees, and seminars to ensure that nursing practice remains current with emerging trends in the care of the consumer with Intellectual Disabilities (ID) * Complete all annual mandatory educational requirements as assigned by Elwyn within the designated timeframe * Oversee direct care staff in provision of healthcare services as assigned by the Health Care Coordinator * Perform cardiopulmonary resuscitation (CPR), first aid, and crisis intervention using agency-trained protocols * Perform other duties as assigned Intermediate Care Facilities (ICF)/ID-Specific Responsibilities * Complete quarterly Nursing Assessments and liaison with the Primary Care Physician/specialty providers regarding identified issues * Review Drug Regimen Reviews on a quarterly basis and liaison with the Primary Care Physician, Pharmacist, and treatment team to address the recommendations * Prepare semi-annual ICF Recertification and Utilization Review documents and review with consulting physician and QI representative; liaison with the Primary Care Physician to ensure medical review and sign off * Ensure 90 day physician orders accurately reflect the current medication and treatment orders through review of orders, Medication Administration Records (MARs) and medication/treatment supplies on hand * Coordinate scheduling and completion of the Annual Nutrition Assessment with Nutritionist * Provide monthly consumer weights to the Nutritionist for ongoing monitoring purposes; report significant changes in the consumer's weight to the Primary Care Physician and Nutritionist * Transcribe new physician orders to MAR IMMEDIATE SUPERVISOR: Senior Director of Community Nursing for PA and NJ DIRECT REPORTS: None CONTACTS: Elwyn consumers, personnel, families/guardians, physicians, health care providers, and service agencies such as pharmacies, hospitals, skilled nursing facilities, student nurses and hospice program personnel EDUCATION/EXPERIENCE/SKILLS REQUIREMENTS: * Licensed as a Registered Nurse in the Commonwealth of Pennsylvania * One (1) year general nursing or medical surgical experience required; additional (1) year of Developmental Disabilities nursing experience preferred * Complete Health Risk Screening Tool (HRST) training and Clinical review training within three (3) months of hire * Demonstrated skill using an electronic medical record system * Excellent planning, communication, customer interaction, collaboration, and documentation skills required * Ability to work in a fast-paced environment and manage and prioritize multiple, often competing, priorities * Demonstrated strong attention to detail * Demonstrated strong time management and organizational skills * Demonstrated excellent judgment with the ability to independently solve problems and make decisions with little or no need for direct supervision * Current CPR and first aid certification * Demonstrated ability to work effectively as part of a team * Must be able to perform CPR and crisis intervention techniques using agency-trained protocols * Demonstrated intermediate experience with Microsoft Office applications, including Word, Excel and Outlook * Knowledge of Electronic Health Record (EHR) / Electronic Medical Record (EMR) preferred * Must have current, valid driver's license in state of residence, 3 years driving experience in the United States, and acceptable driving record PHYSICAL DEMANDS/ENVIRONMENTAL PROFILE: See Physical Demands Checklist below which represents the general physical demands and environment conditions to which the employee holding this position must meet, in addition to the duties and responsibilities listed above, to successfully perform the essential functions of this job. Elwyn will engage otherwise qualified candidates for this position whose disabilities may require reasonable accommodations to enable an individual to perform the essential functions. Elwyn reserves the right to revise or change job duties and responsibilities as needed. This job description is not intended to be an all-inclusive statement of duties and responsibilities of the job, nor does it constitute a written or implied contract. Elwyn is an Equal Opportunity Employer. Elwyn does not discriminate on the basis of race, color, religion, creed, ancestry, pregnancy status, medical condition, gender, gender identity or expression, genetic information, sexual orientation or identity, age, national origin, citizenship, handicap status, marital or family status, mental or physical disability, perceived disability, military or veteran status, political activities or affiliations, or any other characteristic protected under applicable federal, state or local law, ordinance, or regulation.#SHA123