Registered Nurse Case Manager - Pontiac

PACE Southeast Michigan • Pontiac, MI

4d • Onsite

About The Position

The Registered Nurse Case Manager (RNCM) at PACE Southeast Michigan (PACE SEMI) uses the nursing process—assessment, planning, implementation, and evaluation—to care for frail elders with complex needs. The RN demonstrates clinical competence, connects nursing interventions with participant outcomes, and provides effective teaching focused on prevention and treatment. The role leads or directs licensed and non-professional nursing staff in coordinated care, with an emphasis on functional capacity, participant autonomy, and coordination of nursing services.

The RNCM assesses participants during initial intake and routine reevaluations, develops and updates care plans with participants, families, and the multidisciplinary team, administers physician- or NP-ordered medications and treatments, monitors responses, and responds to changes in participant status. The RN provides total patient care, education, supervision, and counseling; evaluates care outcomes; maintains timely and accurate documentation; advocates for participants; and supports participant rights and satisfaction. The position may include rotating after-hours on-call coverage by phone triage or home visits. The RN works in participants’ homes and drives within the PACE SEMI catchment area.

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; driving within the PACE SEMI catchment area is required.
• 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 standardized competencies approved by CMS before working independently.
• Must be medically cleared for communicable diseases and have all immunizations up to date before direct participant contact.
• Able to meet the physical demands of frequent walking, bending, and lifting 40 pounds or more.

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 update plans of care.
• Promote participant autonomy and maximize functional capacity.
• Teach, supervise, and counsel participants and caregivers regarding nursing needs and related concerns, applying adult learning principles.
• Initiate appropriate preventative and rehabilitative procedures or programs.
• Administer physician- or NP-ordered medications and treatments, monitor responses, and notify appropriate medical personnel of changes in participant status.
• Demonstrate knowledge of administered medications, teach participants and families safe medication administration at home, and assess and encourage medication adherence.
• Recognize the significance of abnormal test results and use critical thinking to gather data, plan, and implement care.
• Provide safe, comprehensive care to participants with complex health problems, with attention to participants and families.
• Follow nursing practice standards and 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 monthly and document the supervision.
• Evaluate participant outcomes and progress toward care-plan goals and communicate findings to the multidisciplinary team.
• Revise care plans with the interdisciplinary team in response to physical or psychosocial changes and initiate appropriate actions.
• Participate with participants, families, and the interdisciplinary team in evaluating individual and group responses to care and teaching interventions, and document outcomes at scheduled reviews.
• Maintain accurate, timely records of participant health and functional status, care-plan progress and revisions, and care provided; participate in collection and documentation of Data PACE information.
• Advocate for participants and demonstrate accountability in resolving participant concerns or issues.
• Promote and comply with the Participant Bill of Rights and work toward high levels of participant satisfaction.
• Provide rotating after-hours on-call medical assistance, including phone triage or home visits, as needed.
• Complete 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.
• Participate in or facilitate Quality Assurance projects resulting from data results.
• Assist with implementation of nursing research studies.
• Review nursing and PACE model literature and support adherence to departmental and external care standards through professional meetings, committees, and review of national standards.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed