Lead RNCM

PACE Southeast Michigan•Burt Township, MI

7d•Onsite

About The Position

The Lead Registered Nurse Case Manager (RNCM) for PACE Southeast Michigan (PACE SEMI) uses a systematic nursing process—including assessment, planning, implementation, and evaluation—to care for frail older adults with complex needs. The RNCM demonstrates clinical competence, connects nursing interventions to participant outcomes, and provides effective teaching related to prevention and treatment. The role leads or directs licensed and non-professional nursing staff in coordinating participant care, with a focus on functional capacity, autonomy, and coordination of nursing services. The RNCM assesses participants during initial intake and routine reevaluations, and collaborates with participants, families, and the multidisciplinary team to develop and revise care plans. The position provides and evaluates nursing care, medications, treatments, education, and safety interventions; monitors participant status and outcomes; maintains accurate documentation; and advocates for participants. The RNCM also supervises home health aide services and may provide after-hours on-call assistance on a rotating basis, including phone triage or home visits. The schedule requires a rotating on-call shift. Additional lead duties include distributing the next month's care plan calendar, assigning new participants to RNCMs and LPNs in coordination with the lead social worker, attending designated meetings, coordinating RNCM coverage for interdisciplinary team meetings, supporting and training RNCMs and LPNs, and being prepared to substitute as an IDT lead. The Lead RNCM also performs the responsibilities of an RNCM.

Requirements

Current Registered Nurse licensure in Michigan.
At least one year of experience with a frail or elderly population.
Current State of Michigan driver's license and an acceptable driving record.
Reliable transportation available daily for required driving within the PACE SEMI catchment area.
Ability to establish and maintain interpersonal and interdepartmental relationships.
Ability to apply adult learning principles when planning and delivering education.
Ability to lead and direct licensed and non-professional nursing staff in care delivery.
Must meet a standardized set of competencies approved by CMS before working independently.
Must be medically cleared for communicable diseases and have immunizations up to date before direct participant contact.
Ability to meet the physical demands of frequent walking, bending, and lifting 40 pounds or more.
Availability for a rotating on-call shift.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.

Responsibilities

Assess participant needs and plan nursing care during initial intake and routine reevaluation assessments.
Collaborate with participants, families, and multidisciplinary team members to develop and revise plans of care.
Encourage participant autonomy and maximize functional capacity.
Teach, supervise, and counsel participants and caregivers regarding nursing care and related concerns, using adult learning principles.
Initiate appropriate preventative and rehabilitative procedures or programs to support participant care and safety.
Administer physician- or nurse-practitioner-ordered medications and treatments, monitor responses, and notify appropriate medical personnel of changes in participant status.
Educate participants and families on safe medication administration at home and assess and encourage adherence to medication regimens.
Recognize the significance of abnormal test results and use critical thinking in collecting participant data and planning and implementing care.
Provide safe, comprehensive nursing care to participants with complex health problems, considering the participant and family.
Maintain nursing practice standards and follow applicable policies and procedures for care delivery and medication administration.
Lead and monitor licensed, professional, and non-professional staff delivering nursing care in participants’ homes.
Supervise home health aide services in participants’ homes monthly and document the supervision.
Evaluate participant outcomes and progress toward care-plan goals and communicate findings to the multidisciplinary team.
Collaborate with the Interdisciplinary Team to revise care plans in response to physical or psychosocial changes and initiate appropriate actions.
Evaluate individual and group responses to nursing care and teaching with participants, families, and the Interdisciplinary Team, and document outcomes at scheduled reviews.
Maintain accurate, timely records of participant status, progress, care-plan revisions, care provided, and required PACE data.
Advocate for participants and take accountability for resolving their concerns or issues.
Promote and comply with the Participant Bill of Rights and work toward high participant satisfaction.
Provide rotating after-hours on-call medical assistance when needed, through phone triage or home visits.
Send the following month's care-plan calendar two weeks before the start of the month.
Assign new participants to RNCMs in coordination with the lead social worker and assign new participants to LPNs.
Attend Lead RNCM/SW meetings and NPO, and/or provide business cards to new participants.
Attend IDT meetings, encourage other RNCMs to attend, and coordinate RNCM IDT coverage.
Be prepared to substitute at short notice to lead an IDT meeting.
Support and train RNCMs and LPNs.
Participate in annual mandatory in-service training and screening.
Pursue continuing education and promote professional behavior and growth as a role model.
Participate in or facilitate quality assurance projects and assist with nursing research studies.
Review relevant nursing and PACE literature and support adherence to departmental and external quality standards through professional meetings, committees, and review of national practice standards.
Perform all other RNCM responsibilities.