Nurse Case Manager

1 week ago

Victorville, California, United States HIGH DESERT PACE Full time
Job Overview

Position Summary
The Nurse Case Manager/Care Coordinator operates under the general supervision of the Clinic Manager and with oversight from the PACE Physicians. This role is essential in managing the care of all PACE participants residing in ambulatory or home settings, focusing on assessing health requirements and contributing to individualized care plans. Responsibilities include the initial implementation of nursing care strategies and ongoing evaluations of both individual and family nursing needs.


Key Responsibilities
  • Utilizes technical, organizational, and interpersonal skills to efficiently coordinate scheduling, communication, and billing documentation related to home care services.
  • Ensures seamless delivery of home care services while adhering to all regulatory standards and agency policies.
  • Conducts comprehensive assessments of the home and care needs of a frail elderly demographic, developing tailored care plans accordingly.
  • Guarantees the execution of physician-directed care plans, ensuring timely completion of all necessary tests, procedures, and diagnostics.
  • Effectively communicates any barriers to executing the physician's care plan to the PACE Primary Care Provider or Clinic Manager.
  • Actively engages in Interdisciplinary Team Meetings, ensuring all required documentation and assessments are prepared in advance.
  • Administers skilled nursing care and prescribed treatments to participants in their homes or at the adult day health center, while also demonstrating care techniques to participants and their families.
  • Facilitates effective communication with hospital departments to minimize hospital stays and ensure smooth transitions for clients moving from hospital to alternative care settings.
  • Conducts nursing admission assessments to streamline the admission and care planning process.
  • Provides functional supervision to caregiver staff, directing the delivery of quality paraprofessional care.
  • Assists in developing training systems for in-home caregiver staff in accordance with program needs and regulatory requirements.
  • Compiles and analyzes records, reports, and statistical data for program evaluation and planning.
  • Coordinates daily, weekly, and monthly staff schedules for home care to optimize efficiency and cost-effectiveness.
  • Participates in committees as requested, potentially chairing committees and task forces.
  • Adheres to the philosophy and goals of High Desert PACE.
  • Engages in quality management program activities, including peer reviews.
  • Communicates effectively with clients and their families regarding home care needs and concerns.
  • Advises the Clinic Manager on enhancing accountability of High Desert PACE services to participants and referral sources.
  • Maintains professionalism in appearance and conduct within the clinical environment, recognizing personal limits and seeking guidance when necessary.
  • Attends mandatory staff meetings and training sessions, as well as optional professional development opportunities.
  • Performs additional duties as assigned, including temporary coverage for other sites as needed.

Qualifications
  • Degree/diploma in nursing.
  • Current RN license to practice in California.
  • Bachelor of Science in Nursing preferred.
  • Minimum of one year of experience in providing care or services for a frail or elderly population.
  • Experience in home health agencies or community-based settings preferred.
  • Proficiency in computer operations, including word processing and spreadsheet applications.
  • Strong verbal and written communication skills.
  • Ability to work independently and manage multiple tasks effectively.

Skills and Competencies
  • Understanding of the physical, mental, and social needs of frail older adults.
  • Proficient in physical assessment and chronic disease management.
  • Effective listening and communication skills.
  • Ability to collaborate within an interdisciplinary team.
  • Strong organizational skills and adaptability to changing priorities.

Working Conditions

The working conditions and physical demands outlined here represent those that must be met by an employee to successfully perform the essential functions of this role. Reasonable accommodations may be made for individuals with disabilities. This position requires physical strength to perform essential functions and may involve occasional travel between sites and to members' homes. A valid driver's license and proof of automobile insurance are required.

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