Case Manager, RN

WelbeHealth•Stockton, CA

4h•Hybrid

About The Position

WelbeHealth PACE helps seniors stay in their homes and communities by providing comprehensive medical care and community-based services. We serve the most vulnerable seniors with better quality and compassion in a value-based model, and the Lead Registered Nurse Case Manager directly guides this care as a primary voice on the interdisciplinary team (IDT). Reporting to the Clinical Nurse Manager, the Lead RN Case Manager delivers and oversees all aspects of participant care, including conducting required PACE assessments, developing and following personalized participant care plans, and supporting transition of care coordination.

Requirements

Graduate of an accredited school of nursing and unencumbered RN license
Minimum of two (2) years of nursing experience in a clinical setting with a frail or elderly population preferred
Highly motivated, self-directed, able to execute tasks in a quickly changing environment, as well as able to make sound decisions in emergency situations
Excellent clinical, organizational and communication skills in settings with seniors, their families, and IDT members
Must obtain CPR and First Aid certification within 180 days of hire and maintain certification thereafter; CPR and First Aid certification upon hire preferred

Responsibilities

Serve as a preceptor and peer mentor for RN Case Managers at the direction of the clinic leaders
Take ownership of the outcomes and quality of care for assigned participant panels, working in tandem with the PCP and utilizing clinic resources
Conduct PACE required nursing assessments (minimally every 6 months), educating participants and their support network on acute, chronic, and end-stage conditions
Perform both urgent and routine virtual or in-person follow-up visits as determined by participants’ risk stratification and needs, and as a direct extension to the PCP
Develop and implement a discipline-specific plan of care in collaboration with the IDT, participants, and their families, ensuring the delivery of high quality, value-based care, and capturing assessments, findings, relevant information, and respective actions through their timely and compliant documents in EHR
Attend to the clinical inbox to ensure that orders are completed in a timely manner, test results and documents are reviewed and followed up on, and appropriate actions are taken, documented, and communicated
Assist with specific and relevant Clinical Nurse Manager and Clinic Nurse RN tasks as needed, in support of the clinic, the PCP, and the delivery of participant care