Registered Nurse Case Manager - Westland

PACE Southeast Michigan•Westland, MI

21h•Onsite

About The Position

The Registered Nurse Case Manager (RNCM) at PACE Southeast Michigan uses the nursing process—including assessment, planning, implementation, and evaluation—to care for frail elders with complex needs. The RN demonstrates clinical competence, connects nursing interventions to participant outcomes, and provides effective teaching about prevention and treatment. The RNCM leads or directs licensed and non-professional nursing staff in coordinated care, with a focus on supporting participants’ functional capacity and autonomy and coordinating nursing services. The RNCM assesses participants during initial intake and routine reevaluations, collaborates with participants, families, and the multidisciplinary team to develop and revise plans of care, administers ordered medications and treatments, monitors responses, and responds to changes in participant status. The RNCM teaches and supervises participants and caregivers, initiates preventative and rehabilitative measures, evaluates outcomes, maintains records, advocates for participants, and supports participant satisfaction and rights. The role includes monthly supervision and documentation of home health aide services. After-hours assistance may be provided on a rotating basis by phone triage or home visits; the schedule requires a rotating on-call shift. The position involves working in participants’ homes, which are uncontrolled environments, and driving within the PACE SEMI catchment area. Exposure may include infectious materials, blood-borne pathogens, hazardous waste, and extreme temperatures. Reliable transportation is required. Frequent walking, bending, and lifting of 40 pounds or more may be needed. The employee must be medically cleared for communicable diseases and have current immunizations before direct participant contact.

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.
Ability to establish and maintain interpersonal and interdepartmental relationships.
Ability to apply adult learning principles when planning and implementing educational activities.
Ability to lead and direct licensed and non-professional nursing staff in care delivery.
Must meet a standardized set of CMS-approved competencies before working independently.
Must be medically cleared for communicable diseases and have all immunizations up to date before direct participant contact.
Must be able to meet the physical demands of frequent walking, bending, and lifting 40 pounds or more.
Must be able to work in participants’ homes and tolerate potential exposure to infectious materials, blood-borne pathogens, hazardous waste, and extreme temperatures.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.

Responsibilities

Assess participants’ nursing needs and plan appropriate care during initial intake and routine reevaluation assessments.
Collaborate with participants, families, and multidisciplinary team members to develop participant plans of care.
Promote participants’ functional capacity and autonomy.
Teach, supervise, and counsel participants and caregivers about nursing care and related issues, using adult learning principles.
Initiate preventative and rehabilitative procedures or programs as appropriate for participant care and safety.
Administer physician- or nurse-practitioner-ordered medications and treatments, monitor participant responses, and notify appropriate medical personnel of changes in status.
Demonstrate knowledge of administered medications; teach participants and families safe medication administration at home; and assess and encourage adherence to medication regimens.
Recognize the significance of abnormal test results and apply critical thinking when collecting participant data and planning and implementing care.
Provide safe total patient care to participants with complex health problems, with attention to 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 providing nursing care in participants’ homes.
Provide monthly supervision of home health aide services and document that 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.
Participate with participants, families, and the Interdisciplinary Team in evaluating responses to nursing care and teaching interventions; document outcomes at scheduled reviews.
Maintain accurate and timely records of participant health and functional status, progress, care-plan revisions, and care provided in accordance with policies and procedures.
Participate in collecting and documenting PACE data.
Advocate for participants and take accountability for resolving participant concerns or issues.
Promote and comply with the Participant Bill of Rights and work toward high participant satisfaction.
Provide after-hours on-call medical assistance on a rotating basis, including phone triage or home visits as needed.
Participate in annual mandatory in-service training and screening, including infection control, TB testing, safety training, and BLS training.
Pursue continuing education and professional development, serve as a role model, and promote professional behavior and growth within the health team.
Participate in or facilitate Quality Assurance projects based on data results.
Assist with implementation of nursing research studies.
Review relevant nursing and PACE model literature and support adherence to departmental and external standards through professional meetings, committees, and review of national practice standards.