Care Transition Nurse Manager

Immanuel•Omaha, NE

3d•Onsite

About The Position

Immanuel Pathways PACE® is seeking a Care Transition Nurse Manager for Pathways Omaha in Omaha, Nebraska. The role coordinates and facilitates care transitions for PACE participants admitted to hospitals, short-term or skilled rehabilitation, or long-term care. The Case Manager Registered Nurse advocates for participants and the PACE program to support high-quality care, continuity of services, independence, safety, and quality of life. The position partners with the interdisciplinary team (IDT), physicians, hospitals, contracted facilities, discharge planners, and other service providers. It coordinates discharge planning and related services, monitors participants moving between care settings, documents services in the electronic health record, and identifies and escalates quality-of-care concerns. The role also provides nursing support to clinic RNs and participants as needed, supports compliance and quality improvement, and travels between Immanuel Pathways centers as needed. This is a full-time, weekday day position, scheduled Monday through Friday from 8:00 a.m. to 5:00 p.m., with participation in a seven-day on-call rotation approximately every six weeks. Pay is based on experience, certifications, skills, and education.

Requirements

Graduate of a professional nursing school.
Current Registered Nurse (RN) license in the state of employment.
Two years of nursing experience in a hospital, acute care setting, nursing home, or community-based setting.
One year of experience in case management and/or working with a multidisciplinary team in a healthcare setting.
One year of experience working with frail or elderly people, or completion of job-specific training related to working with the elderly within the first six months of hire.
Valid driver's license, proof of insurance, and reliable transportation.

Nice To Haves

Bachelor’s degree in nursing is preferred.
Nursing experience in a geriatric care setting is preferred.

Responsibilities

Coordinate and facilitate transitions for participants admitted to hospitals, rehabilitation, or long-term care, advocating for participants and quality care.
Exchange relevant participant information with contracted facilities, including participant records, admission orders, directives, and care plans.
Communicate with acute, sub-acute, and long-term care facilities about participant status and discharge needs; relay relevant updates to the interdisciplinary team.
Participate in nursing home rounds and care plan meetings and communicate participant care updates to the interdisciplinary team.
Collaborate with the interdisciplinary team and attending physician to plan discharges and coordinate transitions to home or another facility, including transportation, equipment, supplies, services, and authorizations.
Round at hospitals and collaborate with hospital inpatient care management teams and the interdisciplinary team.
Visit hospitals, skilled nursing facilities, or participants' homes within 24 business hours, or the next business day after a weekend or holiday admission, to address participant and family needs and questions.
Document care coordination and specialized nursing services in the electronic health record in a timely manner and according to documentation standards.
Monitor participants and services at contracted facilities to support appropriate placement, independence, safety, and quality of care.
Collaborate with Quality Managers on quality improvement projects related to care transitions and satisfaction survey outcomes.
Make or coordinate referrals to other agencies or services as needed.
Monitor participants weekly during the first 30 days after transitions between care settings to support seamless service coordination.
Protect privacy and maintain confidentiality of company, employee, participant, and family information.
Analyze skilled services, inpatient utilization, and clinical data to assess the appropriateness and medical necessity of requested and received services.
Identify and escalate quality-of-care issues through appropriate channels.
Collaborate with inpatient medical and skilled nursing teams to secure appropriate options and services.
Work with the Provider Relations Specialist to educate contracted vendors about the PACE philosophy and model of care.
Support clinic RNs with processes, assist with participant treatment, examinations, and testing as needed, and help ensure health and personal care services are provided.
Educate participants, families, and caregivers about care, medications, and treatments as needed.
Practice within the scope of authority, implement the Exposure Control Plan, comply with the Emergency Preparedness Plan, and support quality improvement initiatives.
Complete required ISIS PACE Reviewer training and the applicable security review for system access; maintain current system and process knowledge and communicate it to the interdisciplinary team as applicable.
Participate in continuing education, staff and training meetings, and maintain professional affiliations and required certifications.
Travel between Immanuel Pathways centers as needed and perform other assigned duties.
Participate in the seven-day on-call rotation approximately every six weeks.