Registered Nurse Case Manager

INNOVATIVE INTEGRATED HEALTH • Fresno, CA

1d • $55 - $58 • Hybrid

About The Position

PACE by IIH is empowering senior participants to age at home with dignity through personalized, comprehensive care plans that deliver high-quality health and human services along with strong community support. Through an interdisciplinary and participant-centered model of care, PACE by IIH is committed to improving quality of life, promoting independence, and providing compassionate support tailored to the unique needs of each participant. Our team works collaboratively to deliver innovative, community-based healthcare solutions that allow seniors to remain safely and comfortably in their homes while receiving the care and services they need to thrive.

Requirements

• Graduate of accredited nursing program
• Current California Registered Nurses license
• CPR certification with First Aid Certification
• Minimum of three (3) years of health care experience with emphasis in geriatrics.
• Minimum of one (1) year of documented experience working with a frail or elderly population.
• Minimum of one (1) year prior professional nursing experience.
• Is medically cleared for communicable diseases and has all immunizations up-to-date before engaging in direct participant contact.

Nice To Haves

• Bachelor of Science in Nursing preferred.

Responsibilities

• Assessing participants physical and mental wellness, needs, preferences and abilities, and developing plans to improve.
• Conducting Home Care Nursing assessments to determine the nursing, personal care and equipment needs in the home, preferences and goals of the participants and actively participating in Interdisciplinary Team (IDT) meetings to develop participant care plans.
• Delivering and documenting home care nursing interventions as agreed upon in the participants’ care plans including but not limited to maintaining a healthy and safe environment, promptly and accurately responding to physician orders, and correctly administering medications and performing ordered tests and treatments.
• Provide Timely and accurate documentation of regulatory assessments required for each scheduled participant in the panel within the guidelines of CMS PACE Manual – Chapter 8.
• Must fully complete Competency requirement within allotted time prior to end of orientation or prior to direct contact with participants.
• Providing on-site supervision and instruction to Personal Care Assistants and Licensed Vocational Nurse (LVN) assigned to participants’ homes at least as frequently as specified in the Home Health Agency regulations and more often if necessary.
• Recording participants’ progress, charting referrals, and scheduling home visits
• Tracking and monitoring home care hours and scheduling.
• Remaining alert to pertinent input from other team members, participants, and caregivers and updating IDT promptly of any changes in participants’ condition or medical status.
• Following up with participants who are admitted to in the Skilled Nursing Facility (SNF) or similar level of care facilities outside of acute hospital to ensure continuity of care.
• Working with the PACE Providers and other members of the IDT to manage smooth care transitions between settings (hospitals, skilled nursing facilities, home, etc.) upon proper endorsement of the Community Liaison upon discharge from acute hospital.
• Provide health education and counseling to participants and caregivers experiencing chronic conditions and end-of-life issues.
• Participating in end-of-life care coordination and support.
• In coordination with the Marketing Team, supporting enrollment of prospective participants into the program.
• Participating in end-of-life care coordination and support.
• Evaluating participants’ progress periodically and making adjustments as needed
• Responsible for 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 of care delivery.
• Collaborate with Intake department and Care Coordination Group in supporting newly enrolled participants into the program and their continued needs.
• Facilitate integration of new participants into the Innovative Integrated Health care delivery system, including medication, immunizations, routine monitoring of chronic problems, and nursing care plan development.
• Involved in the development and implementation of Quality Improvement activities; evaluate overall effectiveness of the center, implementing change and quality improvement as needed.
• Will provide phlebotomy services in the participants' home and/or clinic as ordered by the PCP.
• Coordinate participant care with outside contracted service providers, including hospitals, nursing facilities, assisted living facilities, lab, oxygen, etc.
• Communicate with Community Liaison and after-hours on-call staff, following up on issues, as necessary.
• Review participant medical records to ensure timely and accurate clinic staff documentation.
• Supervise clinic staff’s administration of prescribed medications and treatments in accordance with nursing standards.
• Act as liaison with primary care provider in the event of an episodic illness; assist in coordinating services provided by primary care provider.
• Timely and accurate completion of Root Cause Analysis (RCA) reports, Incident reporting and discussing with Care team group for follow up and/or interventions needed to prevent recurrence.
• Maintain confidentiality of participant information.
• Attend and participate in staff meetings, in-services, projects, and committees as assigned.
• Adhere to and support the center’s practices, procedures, and policies including assigned break times and attendance.
• Accept assigned duties in a cooperative manner and perform all other related duties as assigned.
• Participate in on call rotation for after-hours participant needs.
• Be flexible in the schedule of hours worked.
• May be required to use a personal vehicle, if applicable. If using a personal vehicle, a valid California Driver’s License is required.

Benefits

• CARE is central to what we do, prioritizing the well-being, dignity, and independence of our senior participants.
• COMPASSION in every interaction, ensuring kindness, empathy, and understanding guide our care.
• CULTURE that reflects the diverse backgrounds of those we serve and fosters a workplace where every team member feels supported, valued, and empowered to grow.
• COMMUNITY that fosters connection, belonging, and support for participants and their families.
• COMMITMENT to quality improvement, innovation, and delivering healthier outcomes.

What This Job Offers

• Career Level: Entry Level