PACE Registered Nurse Case Manager
Essential Responsibilities:
- Actively participate in the interdisciplinary team by offering clinical expertise in team planning, problem-solving, and processes.
- Develop, implement, and coordinate individualized nursing care for participants using established procedures and policies.
- Assess participants' conditions, request necessary diagnostic tests, and develop treatment plans across all care settings.
- Case manage participant care as indicated for hospitalizations, post-acute care, transitions of care, behavioral health crises, and/or coordination for multiple services for severe health conditions.
- Monitor patients, administer medications, and assist with medical procedures as needed.
- Collaborate closely with the PACE IDT to develop comprehensive and compassionate participant care plans.
- During periods of program scale, growth, or operational need, the RN Care Manager may also provide direct clinic-based nursing, ensuring continuity of care and operational stability while maintaining a primary focus on care management responsibilities.
- Participate in compliance and quality improvement initiatives.
- Educate participants on treatments, self-care, and disease prevention to empower them to manage their health actively.
- Provide direct or indirect nursing care to participants at the clinic, in their homes or other care settings.
- Communicate with participants and their families, offering emotional support and compassionate care.
- Communicate and educate participants and their caregivers emphasizing Age-Friendly care.
- Accurately document in the Electronic Health Record (EHR) in a timely manner.
- Serve on various internal and external committees as required or designated.
- Participate in team meetings, caregiver groups, and special events as needed.
- Provide on-call coverage for direct patient care with other staff as needed.
- Foster a safe and supportive environment conducive to the professional development of healthcare professionals.
Supporting Responsibilities:
- Meet department and company performance and attendance expectations.
- Follow privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
- Perform other duties as assigned.
SUCCESS PROFILE
Work Experience: A minimum of 3 years of nursing experience in various healthcare settings is required. Experience in care management, geriatrics, chronic disease management, home health, or long-term care preferred. At least 1 year of experience working with frail, older adults is required.
Education, Certificates, Licenses: A Registered Nurse with a current, unrestricted Oregon state license is required. Valid CPR certification (BLS or ACLS acceptable) required at time of hire.
Knowledge: Possesses thorough knowledge of community services, providers, vendors, and facilities available to assist members. Demonstrates the ability to use computerized systems for data and document recording and retrieval. Maintains a current clinical knowledge base. Exhibits excellent interpersonal and communication skills. Capable of working independently and as part of a team. Proficient in electronic medical records systems.
Each member of the PACE organization's staff that has direct contact with participants must meet the following conditions:
- Be legally authorized (for example, currently licensed, registered or certified if applicable) to practice in the State in which he or she performs the function or action.
- Only act within the scope of his or her authority to practice.
- Have 1 year of experience working with a frail or elderly population
Meet a standardized set of competencies for the specific position description es
