Registered Nurse Case Manager - Pontiac

PACE Southeast Michigan•Pontiac, MI

1d•Onsite

About The Position

The Registered Nurse Case Manager (RNCM) at PACE Southeast Michigan (PACE SEMI) uses a systematic nursing process—including assessment, planning, implementation, and evaluation—to care for frail elders with complex needs. The RN connects nursing interventions to participant outcomes, demonstrates clinical competence, provides effective teaching on prevention and treatment, and leads or directs licensed and non-professional nursing staff in coordinated care. Care focuses on enhancing functional capacity, encouraging participant autonomy, and coordinating nursing services. The RNCM assesses participants at initial intake and routine reevaluations, and works with participants, families, and the multidisciplinary team to develop and revise plans of care. The role includes providing and monitoring treatments and medications, educating participants and caregivers, monitoring changes in health status, supervising home health aide services, evaluating progress toward care-plan goals, maintaining records, and advocating for participants. The RNCM may provide after-hours assistance through phone triage or home visits as needed and participates in a rotating on-call shift. The position works in participants’ homes, which are uncontrolled environments, and requires driving within the PACE SEMI catchment area. The RN must be medically cleared for communicable diseases and have current immunizations before direct participant contact. Reliable transportation is required daily. Duties may involve exposure to infectious materials, blood-borne pathogens, hazardous waste, extreme temperatures, frequent walking and bending, and lifting 40 pounds or more.

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.
Medical clearance for communicable diseases and up-to-date immunizations before direct participant contact.
Ability to perform frequent walking and bending and, as needed, lift 40 pounds or more.
Meet a standardized set of competencies approved by CMS before working independently.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.

Responsibilities

Assess participants’ needs and plan appropriate nursing care during initial intake and routine reevaluation assessments.
Collaborate with participants, families, and multidisciplinary team members to develop and revise plans of care.
Encourage participant autonomy and maximize functional capacity.
Teach, supervise, and counsel participants and caregivers regarding nursing care and related concerns, using adult learning principles.
Initiate preventative and rehabilitative procedures or programs as appropriate.
Administer physician- or nurse-practitioner-ordered medications and treatments and monitor participant responses.
Notify appropriate medical personnel about changes in participant status.
Educate participants and families on safe medication administration at home and assess and encourage adherence to medication regimens.
Recognize the significance of abnormal test results and apply critical thinking in gathering information and planning and implementing care.
Provide safe, comprehensive nursing 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.
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.
Participate with participants, families, and the interdisciplinary team in evaluating responses to nursing care and teaching, and document outcomes at scheduled reviews.
Maintain accurate and timely records of participant health and functional status, care-plan progress and revisions, and care provided, in accordance with CSI policies and procedures.
Participate in collection and documentation of Data PACE information.
Advocate for participants and take accountability for resolving participant concerns or issues.
Promote the Participant Bill of Rights and work toward high levels of participant satisfaction.
Provide after-hours medical assistance by rotating on-call coverage, 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, participate in or facilitate quality assurance projects, assist with nursing research studies, review relevant literature and PACE information, and attend professional meetings or committees and review national practice standards.
Meet CMS-approved standardized competencies before working independently.