Care Transition Nurse

As a Care Transition Nurse (RN), you will play a vital role in ensuring a seamless transition of care for participants within the PACE of Southwest Michigan program. This position involves coordinating and facilitating care for participants admitted to the hospital, in short-term or skilled rehab care, or long-term care. You will also communicate with various healthcare facilities and collaborate with an interdisciplinary team (IDT) to promote continuity of care. The ideal candidate will be proactive, detail-oriented, and committed to maintaining the highest standards of quality and confidentiality in participant care. Travel is required to nursing and care facilities, hospitals, and participant homes. This is a full-time opportunity.

If you have a deep passion for providing excellent care and aspire to create a meaningful impact, we urge you to apply.

Who is PACE of Southwest Michigan?

PACE (Program for All-Inclusive Care for the Elderly) of Southwest Michigan is a 501(c)(3) organization that seeks to uniquely bridge the health and social supports required to help preserve the independence and dignity of our participants. We provide the necessary medical treatment, support, and social interaction to enable our participants to remain in their homes for as long as possible. The care team consists of physicians, nurses, pharmacists, social workers, therapists, and transportation staff who collaborate daily to ensure comprehensive care.

PACE was born via a partnership formed by 3 local non-profit organizations; Spectrum Health Lakeland (now Corewell), Region IV Area Agency on Aging, and Caring Circle. Since PACE's inception, the organization has expanded its team to over 90 professionals and currently serves over 250 participants and their families within Berrien, Cass, and Van Buren Counties. The unique PACE model of care is centered around the belief that it is better for the well-being of seniors with chronic care needs to be served in their homes and their community whenever possible.

Why join PACE of Southwest Michigan?

In addition to our mission-driven culture and commitment to serving the participants within our community, we also provide:

· Paid time off and a flexible work schedule

· (8) Paid Holidays (New Year's Day, Martin Luther King Jr. Day, Memorial Day, Juneteenth, Independence Day, Labor Day, Thanksgiving Day, Christmas Day).

· Medical, dental, and vision insurance.

· Employer-provided life, short-term disability, and long-term disability insurance.

· 403b retirement plan with up to a 5% match.

· Education and training reimbursement, and more

Education: Bachelor's degree in nursing preferred; professional nursing school graduate required.

Experience: Two (2) years of nursing experience in a hospital, acute care setting, nursing home or community-based setting. One (1) year of experience with case management and/or working with a multidisciplinary team in a healthcare setting. One (1) year of experience working with the frail or elderly population is required, or completion of job-specific training related to working with the elderly population must be completed within the first six months of hire.

Number/Type of Employees Supervised: None

Licensure, Registry, or Certification Required: A valid state driver's license is required, and a current Registered Nurse license in the state of Michigan.

Special Training: Only acts within the scope of practice. Meet a standardized set of orientation and/or individual competencies for the specific position description established by PACE of Southwest Michigan and approved by CMS before working independently.

Immunizations: Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.

Specific Requirements and Considerations: May be subject to exposure and handling of infectious waste, diseases, conditions hazardous chemicals, etc., including potential exposure to TB, AIDS, and/or Hepatitis B.

Ages of Patients Rendered Care: Adult, Geriatric

PM20

Key Responsibilities

· Facilitates the exchange of relevant participant information including but not limited to the participant file of life, facility admission orders, advanced and present directives, and care plan between PACE of Southwest Michigan and the contracted facilities to establish continuity of care.

· Communicates with acute care, sub-acute, and long-term care facilities regarding the status of participants and discharge planning needs. Facilitates communication of related information daily to the Interdisciplinary Team (IDT).

· Participates in nursing home and daily hospital rounding. Attends care plan meetings for participants to monitor the status of health and care received.

· Communicates with the IDT regarding participant care and collaborates with the hospital inpatient care management team for updates.

· Collaborates with IDT and attending physician for discharge to the home or other care facilities including transportation, equipment, supplies, arrangements for services, and related authorizations.

· Visits hospitals, SNFs, or participant's home to ensure participant and/or family needs are met.

· Promptly documents care coordination information in the participant's electronic medical record (EMR) abiding by PACE of Southwest Michigan's documentation standards.

· Monitors status and services of participants at contracted facilities, to ensure participants are maintained in the most appropriate setting while promoting independence, safety, and quality of care.

· Collaborates with PACE of Southwest Michigan quality team on the Quality Improvement Plan related to transitions of care services and related satisfaction survey outcomes.

· Makes referrals, or collaborates with Social Work to make referrals, to other agencies or services as needed.

· Documents in the EMR progress notes on the relevant and specialized nursing services provided.

· Develops relationships with discharge planners in the network.

· Monitor participants weekly during the first 30 days of transitioning from one care setting to the next. Ensures the seamless coordination of services.

· Analyzes skilled services, inpatient utilization, and clinical data available to ensure the appropriateness of medical necessity of services requested and received.

· Identifies and escalates quality of care issues through appropriate channels.

· Collaborates with the inpatient medical team and skilled nursing team to secure appropriate options and necessary services.

· Facilitates weekly discharge huddles.

· Collaborates with the provider relations team to educate contracted vendors on the PACE philosophy and model of care.

· Provides support to Clinic RNs with all related processes as needed.

· Assists in the treatment, examination, and testing of participants.

· Assures certain health and personal care services are provided. Educates participants, family, and caregivers regarding care, medications, and treatments as needed.

· Protects privacy and maintains confidentiality of all company procedures, results, and information about employees, participants, and families.

· Maintains up-to-date knowledge of system\process and communicates to IDT as applicable.

· Participates in continuing education classes and any required staff and training meetings.

· Travels between PACE of Southwest Michigan and various locations as needed.

· Abides by all established PACE of Southwest Michigan policies, rules, and regulations, as well as federal and state regulations that govern the operations of a PACE organization.

· Other duties as assigned within the job scope.

Skills and Knowledge

· Knowledge of physical, mental, and social needs of the frail elderly and their families.

· Superior written and oral communication.

· Ability to maintain accurate records and to prepare clear and concise reports, correspondence, and other written materials.

· Strong relationship-building skills.

· Skilled in facilitating group interaction, decisions, and implementation processes.

· Effectively and efficiently plan, prioritize, and follow up on delegated responsibilities.

· Exceptional problem-solving and critical thinking skills to resolve complex issues.

· Proven experience and basic computer proficiency (Microsoft Office, internet, email, and calendar).

· Thrives while working independently and within a group setting.

· Ability to plan effectively using a proactive approach, keeping appointments, and following through on commitments.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions.

While performing the duties of this job, the employee is regularly required to talk and hear. The employee frequently is required to sit and use hands and fingers and handle or feel objects, tools, or controls. The employee is occasionally required to stand and walk. The employee must be able to travel in various types of weather conditions deemed safe by governing officials.

While performing the duties of this job, the employee is required to frequently move up to 50 pounds and perform the physical demands expected while providing medical care for an elderly population. Specific vision abilities required by this job include close vision, distance vision, and the ability to focus.

Every effort has been made to identify the essential functions of this position. However, this in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

Please be aware that we require employees to pass a background check and drug screen. PACE of SWMI is a non-smoking facility.

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