Nurse Case Manager

Trinity Health

23d

About The Position

The Nurse Case Manager plays a key role in supporting participants within the PACE program by planning, coordinating, implementing, and evaluating comprehensive health and social services. This position serves as a critical liaison among the interdisciplinary team (IDT), participants, caregivers, and community partners to ensure high‑quality, person‑centered care.

Requirements

• Must be a graduate of an accredited Nursing Degree program and possess a current, unencumbered, active license to practice as a Registered Nurse in the state of PACE Organization. BSN preferred. Active CPR Certification required.
• Minimum of two (2) years of demonstrated successful experience in related services with geriatric population.
• Minimum of one (1) year of documented experience working with a frail or elderly population or if less than one (1) year of experience, must receive appropriate training from the PACE organization on working with a frail or elderly population upon hiring.
• Valid driver's license in good standing and proof of insurance required.
• Must have the ability to perform standard clinical procedures according to established protocols and possess initiative, solid problem solving skills and a high level of accuracy and thoroughness in documenting the delivery of services.
• State of North Carolina - Must have Employee Medical Statement that meets the requirements of the Standards completed prior to beginning employment, signed within previous 12 months by an MD, NP or PA, indicating that the employee has no illness or health condition that would pose a risk to others and can perform the duties assigned in the job.
• Must be action-oriented, have business acumen, manage conflict well, be customer focused, have high decision quality, flexibility to adapt to ongoing change and have organizational agility. Ability to work with minimal supervision and exercise independent judgment.
• Possess interpersonal skills to drive collaboration, commitment and productivity when working with crossfunctional teams, customers and end users. Must be comfortable functioning in a virtual, collaborative shared leadership environment.
• Demonstrates superior written and verbal communication and presentation skills appropriate for audience comprehension. Well-developed communication skills, both written and oral, that may be used either in an on-site or virtual environment is required. Able to communicate effectively with individuals and groups representing diverse perspectives.
• Comprehensive to expert proficiency with Microsoft product suite (MS Word, Excel, Power Point, etc.); basic knowledge and experience with electronic mail and calendaring system. Knowledge of systems necessary, experience preferred. Ability to type with speed and accuracy. Ability to use other software as required to perform the essential functions of the job.
• Possesses a high degree of personal accountability, responsibility and independent decision making abilities with the skills to plan, organize, develop, implement and interpret programs, goals, objectives, policies and procedures of the organization in line with mission, vision, and philosophy of TH PACE.
• Excellent organizational skills. Ability to perform multiple duties and functions related to daily operations and maintain excellent customer service skills. Ability to perform frequent detailed tasks and provide immediate service with frequent interruptions. Ability to change and be flexible with work priorities. Strong problem solving skills.
• Ability to research, analyze and assimilate information from various on-site or virtual sources based on technical and experience based knowledge. Must exhibit critical thinking skills and possess the ability to prioritize workload.
• Graduate of an accredited Nursing program with an active, unencumbered RN license (BSN preferred). CPR certification required.
• At least 2 years of experience working with the geriatric population.
• Minimum of 1 year of experience working with frail or elderly individuals (or willingness to complete PACE‑provided training).
• Valid driver’s license, reliable transportation, and proof of insurance.
• Strong clinical skills, problem‑solving ability, and attention to detail.

Nice To Haves

• BSN preferred.

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.
• Demonstrate and model the Mission, Vision, Values, and Guiding Behaviors of Trinity Health PACE.
• Foster a warm, collaborative, and compassionate environment for participants, families, and colleagues.
• Work closely with the IDT to complete assessments, identify care needs, develop care plans, and coordinate 24‑hour care delivery.
• Conduct home visits, support hospital discharge planning, guide participants and families on care needs, and manage service referrals.
• Maintain accurate clinical documentation and uphold all regulatory, ethical, and compliance standards.
• Promote interdisciplinary teamwork, participate in QAPI initiatives, and support survey readiness efforts.
• Mentor and support team members, contribute to department operations, and manage budget/supply needs.
• Provide education, participate in committees, and ensure continuity of care, including on‑call responsibilities as needed.

Benefits

• Day-1 Benefits (Low-cost medical, dental, and vision insurance plans).
• Opportunity to get paid daily – through DailyPay
• Paid holidays and generous Paid Time Off (PTO)
• Up to $4,000 in tuition reimbursement annually
• Discounts with major vendors; AT&T, Verizon, Ford Motor Company, General Motors, Quicken Loans.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 251-500 employees