Care Transition Nurse Manager

Immanuel•Omaha, NE

1d•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, supporting optimal care, continuity, independence, safety, and quality of life in collaboration with an interdisciplinary team and contracted facilities. The position is full-time, Monday through Friday, 8:00 a.m. to 5:00 p.m., with participation in a seven-day on-call rotation approximately every six weeks. The role may require travel between Immanuel Pathways centers. 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 with 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.
Must be currently authorized to work in the United States on a full-time basis.
Background check and drug screen required prior to hire.

Nice To Haves

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

Responsibilities

Coordinate and facilitate transitions for participants admitted to hospitals, rehabilitation, or long-term care facilities.
Exchange relevant participant information with Immanuel Pathways and contracted facilities to support continuity of care.
Communicate with acute, sub-acute, and long-term care facilities about participant status and discharge-planning needs.
Share relevant updates with the Interdisciplinary Team (IDT), including during morning meetings or by email when status changes.
Participate in nursing home rounds and care plan meetings to monitor participant status and communicate with the IDT.
Collaborate with the IDT and attending physician on discharge planning and coordinate discharges, transportation, equipment, supplies, services, and authorizations.
Round at hospitals daily to coordinate with the hospital inpatient care management 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.
Document care coordination and specialized nursing services in the electronic health record in a timely manner and according to documentation standards.
Monitor participants at contracted facilities and help ensure they are in the most appropriate setting while promoting independence, safety, and quality of care.
Collaborate with Quality Managers on quality improvement projects related to transitions of care and satisfaction survey outcomes.
Make referrals or collaborate with Social Work to make referrals to other agencies or services as needed.
Monitor participants weekly during the first 30 days after transitions between care settings to help ensure seamless coordination of services.
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 on 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.
Comply with the scope of nursing practice, the Exposure Control Plan, and the Emergency Preparedness Plan; protect privacy and confidentiality; and support quality improvement initiatives.
Complete required ISIS PACE Reviewer training and the Security Review process for system access, maintain current system and process knowledge, and communicate relevant information to the IDT.
Participate in continuing education, required staff and training meetings, and professional affiliations; maintain required certifications.
Travel between Immanuel Pathways centers as needed and perform other assigned or requested duties.