Senior RN Care Coordinator

2 weeks ago

Southfield, United States PACE Southeast Michigan Full time
Job Overview

SENIOR RN CARE COORDINATOR

The Senior RN Care Coordinator (RNCC) at PACE Southeast Michigan (PACE SEMI) employs a comprehensive approach to nursing that encompasses all facets of the nursing process, including assessment, planning, execution, and evaluation of elderly individuals with intricate health requirements. The RNCC establishes a clear connection between nursing actions and participant outcomes, showcases clinical proficiency, and engages in effective patient education in both preventive and therapeutic domains. The RNCC adeptly leads and guides both licensed and non-licensed nursing personnel in the synchronized delivery of care to participants enrolled in the PACE Southeast Michigan initiative. The care approach prioritizes enhancing functional abilities, fostering independence in all care aspects, and ensuring the seamless coordination of nursing services.

KEY RESPONSIBILITIES:

  • The RNCC evaluates participants' needs and formulates suitable nursing care plans during the Initial Intake Assessment and subsequent Re-Evaluation Assessments.
  • The RNCC collaborates with participants and their families, along with all members of the multidisciplinary team, to develop personalized care plans.
  • The RNCC promotes participants' functional independence by encouraging self-management in all care dimensions.
  • The RNCC instructs, oversees, and advises participants or caregivers on nursing care requirements and related issues, utilizing adult learning principles for educational initiatives.
  • The RNCC initiates preventive and rehabilitative strategies or programs tailored to participants' care and safety needs.
  • The RNCC administers medications and treatments as prescribed by the physician or nurse practitioner, monitoring participants' responses and notifying relevant medical personnel of any changes in condition.
  • The RNCC demonstrates a thorough understanding of the medications administered and educates participants and families on safe medication practices at home, promoting adherence to medication regimens.
  • The RNCC identifies and interprets abnormal test results, employing critical thinking skills in data collection, care planning, and implementation.
  • The RNCC delivers comprehensive patient care to participants with complex health issues, focusing on individual needs and family dynamics.
  • The RNCC upholds all nursing practice standards and adheres to organizational policies and procedures regarding care delivery and medication management.
  • The RNCC supervises and evaluates the performance of licensed and non-licensed staff in providing nursing care to participants in their homes, ensuring compliance with care standards.
  • The RNCC assesses participant outcomes and progress towards care plan objectives, sharing this information with the multidisciplinary team.
  • The RNCC collaborates with the interdisciplinary team to adjust care plans based on changes in participants' physical or psychosocial conditions, initiating appropriate actions.
  • The RNCC engages with participants, families, and team members to assess and document responses to nursing care and educational interventions during scheduled reviews.
  • The RNCC maintains precise and timely records of participants' health status, progress towards care plan goals, and care provided, in accordance with organizational policies.
  • The RNCC advocates for participants, demonstrating accountability in addressing their concerns and issues.
  • The RNCC promotes and adheres to the Participant Bill of Rights, striving for high levels of participant satisfaction.
  • The RNCC may provide after-hours on-call medical support on a rotating basis, including phone triage or home visits as necessary.
  • The schedule includes a rotating on-call shift.

QUALIFICATIONS:

  • Must be a Registered Nurse with active Michigan licensure; a Bachelor of Science in Nursing (BSN) is preferred.
  • The RNCC participates in mandatory annual training and screenings, including infection control, TB testing, safety protocols, and BLS certification.
  • The RNCC is responsible for personal development through continuing education and serves as a role model within the healthcare team.
  • A valid Michigan driver's license and a clean driving record are required.
  • The RNCC must establish and maintain effective interpersonal and interdepartmental relationships.
  • The RNCC should apply adult learning principles in planning and executing educational activities.
  • The RNCC must lead and direct other nursing staff in delivering care effectively.
  • The RNCC may participate in quality assurance initiatives based on data analysis.
  • The RNCC may assist in nursing research studies.
  • The RNCC reviews current literature relevant to nursing practice and the PACE model of care.
  • The RNCC ensures compliance with departmental and external standards in delivering quality care by attending professional meetings and reviewing national practice standards.
  • Must meet standardized competencies as approved by CMS after working independently.
  • A minimum of one year of experience working with frail or elderly populations is required.

WORK ENVIRONMENT:

  • Work is conducted in participants' homes, which may present uncontrolled conditions.
  • Potential exposure to infectious materials, blood-borne pathogens, and hazardous waste is possible.
  • Medical clearance for communicable diseases and up-to-date immunizations are required for direct participant contact.
  • Driving within the PACE SEMI service area is necessary, with potential exposure to extreme weather conditions. Reliable transportation is essential.
  • Frequent physical activities, including walking, bending, and lifting up to forty pounds or more, may be required.

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