Registered Nurse Case Manager

PACE Southeast Michigan • Dearborn, MI

13d • Onsite

About The Position

The Registered Nurse Case Manager (RNCM) of the PACE Southeast Michigan (PACE SEMI) utilizes a systematic approach to nursing practice which incorporates all aspects of the nursing process including, assessment, planning, implementation and evaluation of frail elders with complex needs. The RN demonstrates a direct relationship between nursing interventions and participant outcomes, demonstrates clinical competence and engages in effective patient teaching in areas of prevention as well as treatment. The RN effectively leads or directs licensed and non-professional nursing staff in the coordinated delivery of care to participants of the PACE Southeast Michigan program. The focus of care is one that enhances functional capacity, encouraging autonomy in all aspects of care, and assures coordination of all nursing care.

Requirements

• Must be a Registered Nurse with current Michigan licensure, BSN preferred.
• Participates in annual, mandatory in-service training and screening, including but not limited to: infection control, TB testing, safety training, and BLS training.
• Assumes responsibility for self-development through continuing education, utilizing resources within the health care system or elsewhere; the RN promotes professional behavior and growth by serving as a role model within the health team.
• Must possess a current State of Michigan driver’s license and maintain an acceptable driving record.
• Ability to establish and maintain interpersonal and interdepartmental relationships.
• Ability to apply principles of adult learning in planning and implementing educational activities.
• Ability to lead and direct other licensed and non-professional nursing staff in the delivery of care.
• Participates in and/or facilitates Quality Assurance projects resulting from data results.
• Assists with the implementation of nursing research studies.
• Reviews current periodical literature relevant to the general practice of nursing as well as information pertaining to the PACE model of care.
• Ensures adherence to departmental and external standards in the provision of quality focused care by attendance at professional meetings/committees and review of national standards of practice.
• Must meet a standardized set of competencies (approved by CMS) before working independently.
• Must have one (1) year of experience with a frail or elderly population.

Nice To Haves

• BSN preferred.

Responsibilities

• Assesses participants’ needs and plans for appropriate nursing care upon the Initial Intake Assessment as well as upon routine Re-Evaluation Assessments.
• Works and collaborates with the participant and the family, as well as all members of the multidisciplinary Team in developing the participant’s plan of care.
• Maximizes the participant’s functional capacity by encouraging autonomy in all aspects of care.
• Teaches, supervises and counsels the participant, or caregiver regarding nursing care needs and other related problems.
• Utilizes adult learning principles when planning for and implementing educational information to the participants, caregivers or family members.
• Initiates preventative and rehabilitative procedures or programs as appropriate for the participants’ care and safety.
• Administers medications and treatments, as ordered by the physician/NP, and monitors the participant’s response.
• Notifies the appropriate medical personnel of changes in the participant’s status.
• Demonstrates knowledge of the medications he/she administers and instructs the participant/family in safe administration of medication in the home. Assesses for and encourages compliance with medication regimen.
• Recognizes and understands the significance of abnormal test results and utilizes critical thinking skills when gathering participant data, planning for, and implementing care.
• Provides safe total patient care to participants with complex health problems with a focus on the individual participant and the family.
• Maintains all standards of nursing practice and follows hospital policies/procedures for care delivery and medication administration.
• Leads and monitors licensed and other professional and non-professional staff in the delivery of nursing care to the participant in the home.
• Responsible for monthly supervision and subsequent documentation of home health aide services provided in the participant’s home.
• Evaluates participant outcomes and or progress toward achieving the objectives/goals of the care plan and communicates this information among other members of the Multidisciplinary Team.
• Collaborates with the Interdisciplinary Team to revise the plan of care based on changes in the participants’ physical or psychosocial status, and initiates actions that are consistent with the changes in status.
• Participates with patients, families and members of the Interdisciplinary Team to evaluate/measure the individual and group response to nursing care and teaching interventions and documents the outcomes of the problems identified at every scheduled review.
• Maintains accurate and timely records of participant’s functional /health status, progress toward care plan outcomes, revisions to care plans, care given, etc. All charting and documentation is performed in accordance with CSI policies/procedures.
• Participates in the collection and documentation of Data PACE information.
• Advocates to others on behalf of the participant, and demonstrates accountability in resolving participant concerns or issues.
• Understands, complies with and promotes the Participant Bill of Rights and assesses and works toward achieving high levels of participant satisfaction.
• May provide after hours on-call medical assistance on a rotating basis, via phone triage or after hours home visits to participants as needed.
• Schedule requires a rotating on call shift.

Benefits

• Our employees are compassionate, curious, accountable, courageous, and authentic.
• They make choices according to what is best for our participants and strive to make a difference.
• For several years, they have made us a Top Workplace in our area.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior