Nurse Case Manager

1 week ago

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

The Nurse Case Manager/Care Coordinator operates under the general supervision of the Clinic Manager and the guidance of PACE Physicians. This role is crucial in managing the care of all PACE participants residing in home or ambulatory settings, focusing on assessing health requirements and contributing to the development of personalized care plans.


Key Responsibilities
  • Utilizes technical, organizational, and interpersonal skills to effectively coordinate scheduling, communication, and billing documentation related to home care services.
  • Ensures seamless delivery of home care services while adhering to all regulatory requirements and agency policies.
  • Conducts comprehensive assessments to identify the health and care needs of a vulnerable elderly population, formulating tailored care plans.
  • Implements physician-directed care plans, ensuring timely completion of necessary tests, procedures, and diagnostics.
  • Communicates any obstacles in executing the physician's care plan to the PACE Primary Care Provider or Clinic Manager.
  • Actively engages in Interdisciplinary Team Meetings, ensuring all 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 educating families on nursing care practices.
  • Collaborates with hospital departments to optimize patient transitions from hospital to home care, minimizing hospital stays.
  • Conducts nursing admission assessments to streamline the admission and care planning process.
  • Provides functional supervision to caregiver staff, ensuring high-quality paraprofessional care.
  • Assists in developing training and supervision systems for in-home caregiver staff in accordance with program needs and regulatory standards.
  • Utilizes records, reports, and statistical data for the evaluation and planning of assigned programs.
  • Coordinates staff schedules for home care to ensure efficient and cost-effective service delivery.
  • 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 activities, including peer reviews.
  • Communicates effectively with clients and their families regarding home care needs and concerns.
  • Advises the Clinic Manager on improving accountability of services to participants and referral sources.
  • Maintains professionalism in appearance and conduct within the clinical environment, seeking guidance when necessary and responding positively to feedback.
  • 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 is required. Current RN license to practice in California is mandatory. A Bachelor of Science in Nursing is preferred.

A minimum of one year of experience in providing care or services to a frail or elderly population is required, with preference given to candidates with experience in home health agencies or community-based settings. Two years of community nursing experience is preferred.

Proficiency in computer operations, including word processing and spreadsheet applications, is essential. Candidates must possess excellent verbal and written communication skills, the ability to work independently, and strong organizational capabilities.


Skills and Abilities

Knowledge of the physical, mental, and social needs of frail older adults is crucial. Candidates should demonstrate effective skills in physical assessment and chronic disease management, as well as the ability to work collaboratively within an interdisciplinary team.

Strong organizational skills and the ability to manage shifting priorities based on participant needs are essential.


Working Conditions

The working conditions described are representative of those required to successfully perform the essential functions of this role. Reasonable accommodations may be made for individuals with disabilities.

Must be able to adhere to the required schedule and possess the physical strength necessary to perform essential job functions. Occasional travel between sites and to members' homes is required, necessitating the use of a personal vehicle and a valid driver's license, along with proof of automobile insurance.

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