Registered Nurse, Home Care Case Manager

Loretto•Village of North Syracuse, NY

1d•$78,562 - $88,234

About The Position

PACE CNY is seeking a Home Care Case Manager, RN, responsible for providing high-quality in-home care and ensuring participant safety. The role provides primary support to the Physician, Nurse Practitioner, Director of Clinical Services, and Home Care Manager. The schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m. The case manager assesses participants, develops and evaluates individualized care plans, conducts home visits, monitors clinical and functional changes, and documents care and communications in accordance with applicable policies. The position also provides education to participants, families, caregivers, and staff; delegates and supervises nursing and paraprofessional tasks; and collaborates with the PACE Interdisciplinary Team, rehabilitation staff, and outside providers. The role advocates for participants, contributes to quality and compliance activities, and completes reassessments and care-plan documentation on time.

Requirements

Degree from an accredited school of nursing.
Current New York State license and registration as a registered professional nurse.
At least one year of recent RN experience in an acute-care or long-term-care setting.
Valid unrestricted driver’s license and a reliable, insured vehicle.
Proven patient-assessment skills.
Current knowledge of nursing best practices and standards of care.
Proficiency in the care-planning process.
Ability to work independently with minimal direct supervision.
Excellent interpersonal and communication skills, including the ability to work with clients, residents, and families from diverse backgrounds and with physical, sensory, or mental impairments.
Ability to involve family members or other support persons while providing care.
Excellent organizational skills.
Ability to read, write, and speak clearly in English.
Proficiency in MS Office and electronic medical record programs.
An equivalent combination of education and experience that provides proficiency in the listed responsibilities may substitute for the stated education and experience requirements.

Responsibilities

Assess participants and develop, implement, and evaluate individualized care plans.
Conduct home visits to assess, organize, implement, and evaluate care; report changes and concerns to providers and document appropriately.
Review the order inbox in TruChart or similar software daily and obtain, transcribe, and implement physician orders in a timely manner.
Demonstrate appropriate clinical knowledge and skill, meet participant-specific needs, document care, and implement Pathways as needed.
Observe and assess changes in clinical or functional status and initiate appropriate follow-up.
Teach and counsel participants and caregivers on maintaining health and preventing illness or complications.
Educate participants and families, use educational handouts, develop teaching plans as needed, and evaluate and adjust teaching plans.
Educate staff and document required competencies and orientation to care plans.
Delegate tasks to the appropriate discipline and supervise, instruct, and guide nursing and paraprofessional staff.
Educate and monitor staff regarding delegated special-circumstance tasks and complete aide supervisions promptly.
Respond to aide communications promptly and investigate issues as needed.
Include Home Health Aides and LPNs and/or their feedback in care-planning meetings.
Coordinate with the Rehabilitation department on Safe Participant Handling solutions.
Contribute to the PACE Interdisciplinary Team and act as a liaison among participants, families or caregivers, home care supervisors, and the team.
Attend participant care-plan meetings and establish measurable goals with the Interdisciplinary Team and Home Care Life Plans.
Advocate for participants’ desires, wishes, and needs and participate in team problem-solving.
Provide leadership among coworkers, communicate effectively, and promote team building through staff meetings and orientation.
Participate in and demonstrate understanding of the QAPI process.
Promote professional growth and nursing through professional associations, educational conferences, volunteer activities, and similar opportunities when possible.
Follow compliance policies, procedures, and regulations and promote compliance-oriented conduct.
Meet quality standards, practice safety awareness, and report potential safety or environmental issues.
Arrive on time and prepared to work and document thoroughly, appropriately, and promptly in accordance with medical-record policies.
Complete participant reassessments by their due dates and document visits, calls, orders, and other relevant information.
Follow medication-administration, transcription, and MAR-process policies.
Document a thorough assessment of participant needs and a Plan of Care every six months and as needed, including required regulatory items.
Promote Loretto’s mission, values, vision, and strategic goals; treat others with dignity, professionalism, and kindness.
Provide excellent internal and external customer service and demonstrate reliability, attendance, and strong work ethics.
Attend and participate in required meetings and training, follow policies and codes of conduct, and comply with health, safety, HIPAA, and other regulatory requirements.
Perform related duties as assigned.