Nurse Case Manager

Trinity Health•Alexandria, VA

About The Position

POSITION PURPOSE The Nurse Case Manager is responsible for planning, coordination, implementation and evaluation of health care and social services to participants at the PACE program. Serves as the liaison between the interdisciplinary team (IDT), participants, caregivers and community agencies. ESSENTIAL FUNCTIONS 1. Know, understand, incorporate, and demonstrate the Mission, Vision, Values and Guiding Behaviors of Trinity Health and Trinity Health PACE (TH PACE) in behaviors, practices, and decisions. 2. Consistently demonstrate (leads by example) TH PACE Values to all internal and external customers (participants, visitors, volunteers, and colleagues.) Create and maintain an atmosphere of warmth, propagating a calm environment throughout the office. 3. Execute assignments in a culture that is shared and collaborative across all divisions within TH PACE. 4. Reflects the skills knowledge and abilities serving in the role of a leader. Define and share a strategy and vision; align resources toward achievement of organization results; grow and sustain the organization; identify, lead, and embrace change. 5. Establish and/or maintain as a member of the leadership team a plan to achieve operating goals. 6. Promote and maintain collaborative relationships with managers, peers, direct reports and customers by effectively fostering a team environment, building consensus and resolving conflicts. 7. Maintain department budget, place orders for equipment and supplies as necessary. Identify financial vulnerabilities and make cost reduction recommendations as needed. 8. Evaluate, develop, mentor, coach, counsel and discipline department staff. Supports other personnel from other departments through coaching and mentoring to help achieve optimum standard of excellence. Addresses issues of concern through courageous conversation and notifies department manager of any interactions requiring attention. 9. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, TH PACE Corporate Integrity Program, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior. 10. In light of a disaster will know your disaster recovery, crisis management and business continuity plans and act within your role that is developed within the business continuity plan. Which may include working at another location, remotely from home, and maintaining constant contact with key personnel. 11. Attend and participate in scheduled training, in-service training, mandatory annual in-service training and educational classes as required/needed. 12. Participate as a member of the interdisciplinary team (IDT), including 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 for 24-hour care delivery. 13. Acts as liaison between the interdisciplinary team (IDT), participants, caregivers and community agencies. 14. Actively serves on the Quality Assessment and Process Improvement (QAPI) Committee if required. Involved in the development and implementation of QAPI activities. 15. Coordinate hospital discharges in conjunction with the interdisciplinary team (IDT) and attending physician. Communicates updates to family or caregivers as needed. 16. Perform home visits as needed to assess living environment and support system. 17. Maintain current written/electronic records and documents related to participant care. 18. Communicate, counsels and guides participants and families regarding service needs and concerns; makes referrals as appropriate. 19. Manage and facilitate coordination and collaboration of participant care will all clinicians and caregivers. Responsible for identification of need and utilization of clinical services. 20. Actively participates in the coordination of efforts towards survey preparedness. When necessary, contribute to the plan of correction for department deficiencies. 21. Responsible for adherence to all regulations, both federal and state, which govern the operations of a PACE organization and a licensed adult day care center. Follow Occupational Safety and Health Administration (OSHA) guidelines. 22. Counsel and educate participants, families and staff on health-related topics. 23. Actively serves on various committees that support the daily operations of the program. 24. Provide on-call coverage during center hours of non-operation, if applicable. 25. Communicate with weekend and afterhours on-call staff, following up on issues as necessary. 26. Maintain confidentiality of participant information. Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law. Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs. For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.

Responsibilities

Know, understand, incorporate, and demonstrate the Mission, Vision, Values and Guiding Behaviors of Trinity Health and Trinity Health PACE (TH PACE) in behaviors, practices, and decisions.
Consistently demonstrate (leads by example) TH PACE Values to all internal and external customers (participants, visitors, volunteers, and colleagues.) Create and maintain an atmosphere of warmth, propagating a calm environment throughout the office.
Execute assignments in a culture that is shared and collaborative across all divisions within TH PACE.
Reflects the skills knowledge and abilities serving in the role of a leader. Define and share a strategy and vision; align resources toward achievement of organization results; grow and sustain the organization; identify, lead, and embrace change.
Establish and/or maintain as a member of the leadership team a plan to achieve operating goals.
Promote and maintain collaborative relationships with managers, peers, direct reports and customers by effectively fostering a team environment, building consensus and resolving conflicts.
Maintain department budget, place orders for equipment and supplies as necessary. Identify financial vulnerabilities and make cost reduction recommendations as needed.
Evaluate, develop, mentor, coach, counsel and discipline department staff. Supports other personnel from other departments through coaching and mentoring to help achieve optimum standard of excellence. Addresses issues of concern through courageous conversation and notifies department manager of any interactions requiring attention.
Maintains a working knowledge of applicable Federal, State, and local laws and regulations, TH PACE Corporate Integrity Program, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
In light of a disaster will know your disaster recovery, crisis management and business continuity plans and act within your role that is developed within the business continuity plan. Which may include working at another location, remotely from home, and maintaining constant contact with key personnel.
Attend and participate in scheduled training, in-service training, mandatory annual in-service training and educational classes as required/needed.
Participate as a member of the interdisciplinary team (IDT), including 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 for 24-hour care delivery.
Acts as liaison between the interdisciplinary team (IDT), participants, caregivers and community agencies.
Actively serves on the Quality Assessment and Process Improvement (QAPI) Committee if required. Involved in the development and implementation of QAPI activities.
Coordinate hospital discharges in conjunction with the interdisciplinary team (IDT) and attending physician. Communicates updates to family or caregivers as needed.
Perform home visits as needed to assess living environment and support system.
Maintain current written/electronic records and documents related to participant care.
Communicate, counsels and guides participants and families regarding service needs and concerns; makes referrals as appropriate.
Manage and facilitate coordination and collaboration of participant care will all clinicians and caregivers. Responsible for identification of need and utilization of clinical services.
Actively participates in the coordination of efforts towards survey preparedness. When necessary, contribute to the plan of correction for department deficiencies.
Responsible for adherence to all regulations, both federal and state, which govern the operations of a PACE organization and a licensed adult day care center. Follow Occupational Safety and Health Administration (OSHA) guidelines.
Counsel and educate participants, families and staff on health-related topics.
Actively serves on various committees that support the daily operations of the program.
Provide on-call coverage during center hours of non-operation, if applicable.
Communicate with weekend and afterhours on-call staff, following up on issues as necessary.
Maintain confidentiality of participant information.