Description
Who We Are
Are you interested in working for an organization whose mission is to enable frail, underserved, and multicultural senior communities to live independently at home and in their communities, for as long as possible?
Fresno Program of All-Inclusive Care for the Elderly (PACE) is dedicated to providing its participants with comprehensive health and social supports that are proven to effectively manage chronic conditions and to reduce the risk for premature institutionalization. PACE staff are leaders in the “aging in place” industry and we have had the honor of serving Fresno, Bakersfield and Orange County seniors and their families/caregivers.
Job Summary
The Registered Nurse Case Manager (RN CM) is responsible for assessing, coordinating, monitoring, and providing health care services and case management for an assigned panel of Innovative Integrated Health participants.
Essential Job Functions
- Assessing participants' physical and mental wellness, needs, preferences and abilities, and developing plans to improve.
- Conducting Home Care Nursing assessments to determine the nursing, personal care and equipment needs in the home, preferences and goals of the participants and actively participating in Interdisciplinary Team (IDT) meetings to develop participant care plans.
- Delivering and documenting home care nursing interventions as agreed upon in the participants’ care plans including but not limited to maintaining a healthy and safe environment, promptly and accurately responding to physician orders, and correctly administering medications and performing ordered tests and treatments.
- Instructing the participant, family and caregivers regarding the disease process, self-care techniques, and prevention strategies.
- Providing on-site supervision and instruction to Personal Care Assistants and Licensed Vocational Nurse (LVN) assigned to participants’ homes at least as frequently as specified in the Home Health Agency regulations and more often if necessary.
- Recording participants’ progress, charting referrals, and scheduling home visits.
- Tracking and monitoring home care hours and scheduling.
- Remaining alert to pertinent input from other team members, participants, and caregivers and updating IDT promptly of any changes in participants’ condition or medical status.
- Following up with participants who are admitted into the hospital and/or Skilled Nursing Facility (SNF) to ensure they are satisfied with services and are seen by their Primary Care Physician (PCP) upon discharge.
- Working with the PACE Providers and other members of the IDT to manage smooth care transitions between settings (hospitals, skilled nursing facilities, home, etc.).
- In coordination with the Marketing Team, supporting enrollment of prospective participants into the program.
- Participating in end-of-life care coordination and support.
- Listening to participants' concerns and providing counseling or intervention as required.
- Evaluating participants’ progress periodically and making adjustments as needed.
- Responsible for completion of initial medical history, physical exam, and functional nursing assessments of each new participant and semi-annual, annual, and unscheduled assessments; communicate changes in participant health or functional status to the interdisciplinary team members and participate in development of the plan of care and coordination of care delivery.
- Involved in the development and implementation of Quality Improvement activities; evaluate overall effectiveness of the center, implementing change and quality improvement as needed.
- Facilitate integration of new participants into the Innovative Integrated Health care delivery system, including medication, immunizations, routine monitoring of chronic problems, and nursing care plan development.
- Will provide phlebotomy services in the participants' home and/or clinic as ordered by the PCP.
- Coordinate participant care with outside contracted service providers, including hospitals, nursing facilities, assisted living facilities, lab, oxygen, etc.
- Communicate with weekend and after-hours on-call staff, following up on issues as necessary.
- Review participant medical records to ensure timely and accurate clinic staff documentation.
- Supervise clinic staff’s administration of prescribed medications and treatments in accordance with nursing standards.
- Act as liaison with primary care provider in the event of an episodic illness; assist in coordinating services provided by primary care provider.
- Provide health education and counseling to participants and caregivers experiencing chronic conditions and end-of-life issues.
- Ensure that all clinic areas are stocked with necessary supplies and materials and that all emergency equipment is available and in working order.
- Maintain confidentiality of participant information.
- Attend and participate in staff meetings, in-services, projects, and committees as assigned.
- Adhere to and support the center’s practices, procedures, and policies including assigned break times and attendance.
- Accept assigned duties in a cooperative manner; and perform all other related duties as assigned.
- Participate in on-call rotation for after-hours participant needs.
- Be flexible in the schedule of hours worked.
- May require use of personal vehicle.
Working Conditions and Physical Demands
The working conditions and 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 the essential functions.
- Variable working conditions (center, hospital, nursing facility, participant home, or elsewhere).
- Some undesirable conditions at the center may include exposure to odors, fumes, infections, dust, and dirt, which may be objectionable.
- Local car travel is frequently necessary; out-of-town travel is minimal.
- While performing the duties of this job, the employee is regularly required to sit and talk, hear, and to stand and walk.
Requirements
Experience
- Minimum of three (3) years of health care experience with emphasis in geriatrics.
- Minimum of one (1) year of documented experience working with a frail or elderly population.
Knowledge, Skills, and Abilities
- Broad knowledge base of physical, mental, and social needs of the frail elderly population.
- Knowledge of medical equipment and instruments.
- Knowledge of common safety hazards and precautions to establish a safe work environment.
- Possess management and leadership skills.
- Experienced in physical assessment and triaging.
- Skilled in identifying problems and recommending solutions.
- Able to effectively prepare and maintain records, write reports, and respond to correspondence.
- Clinical competency in home health care, effective care planning and utilization management.
- Ability to react calmly and effectively in emergency situations.
- Able to establish and maintain effective working relationships with participants, medical staff, staff members, and family caregivers in a pleasant, patient, and professional manner.
- Well organized, dependable, flexible, and resourceful.
- Effective oral and written communication skills.
- Computer skills required.
Education and Certification
- Current California Registered Nurses license.
- CPR certification with First Aid Certification.
- Bachelor of Science in Nursing preferred.
- Is medically cleared for communicable diseases and has all immunizations up-to-date before engaging in direct participant contact.
Core Values
- Respect at the core of our interactions.
- Honesty and Integrity with every endeavor.
- Patient-Centered care aligned with participant values, beliefs, and preferences.
- Encouragement that motivates and empowers others to be the best they can be.
- Quality Care that is efficient, transformative and innovative.
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