Registered Nurse, Home Care Case Manager

Loretto Management Corporation•Syracuse, NY

11h

About The Position

PACE CNY is hiring 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 Home Care Case Manager assesses participants, develops and implements individualized care plans, evaluates care, and makes home visits. The nurse monitors changes in clinical and functional status, communicates concerns, documents care, processes physician orders, and completes required reassessments. The role also teaches participants, caregivers, and staff; delegates and supervises tasks performed by nursing and paraprofessional staff; and collaborates with the PACE Interdisciplinary Team, rehabilitation department, families, providers, and home care staff. The position requires timely and thorough documentation in accordance with medical-record policies, attention to medication administration and transcription procedures, participation in care-plan meetings and quality-improvement activities, and adherence to safety, compliance, and regulatory requirements. The nurse advocates for participants, contributes to team problem-solving, supports staff orientation and development, and performs other related duties as assigned.

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 reliable, insured vehicle.
Proven patient-assessment skills.
Current knowledge of nursing best practices and care.
Proficiency in the care-planning process.
Ability to work independently with minimal direct supervision.
Excellent interpersonal and communication skills, including the ability to communicate effectively 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.
Equivalent combinations of education and experience that provide proficiency in the listed areas of responsibility may substitute for the stated education and experience requirements.

Responsibilities

Assess participants and develop, implement, and evaluate individualized care plans.
Make 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; obtain, transcribe, and implement physician orders in a timely manner.
Monitor participants for changes in clinical or functional status and initiate appropriate follow-up actions.
Teach and counsel participants and caregivers about health maintenance and illness or complication prevention; create and evaluate teaching plans and use educational handouts as appropriate.
Educate staff, document required competencies and care-plan orientation, and delegate, supervise, instruct, and guide nursing and paraprofessional staff.
Monitor delegated tasks, including special-circumstance tasks, and complete and document aide supervisions in a timely manner.
Respond to aide communications, investigate issues as needed, and 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 IDT and Home Care Life Plans.
Advocate for participants’ desires, wishes, and needs and participate in team problem-solving.
Support team building, staff meetings, staff orientation, and welcoming new staff.
Participate in and demonstrate understanding of the QAPI process.
Promote professional growth and the nursing profession through professional associations, educational conferences, volunteer activities, or similar activities when possible.
Follow compliance policies, procedures, and regulations; promote compliance-oriented behavior.
Maintain safety awareness, report potential safety or environmental issues, and follow safety policies and procedures.
Document visits, calls, orders, assessments, and other care appropriately and on time, following medical-record policies and procedures.
Complete participant reassessments by their due dates and document a thorough assessment and Plan of Care every six months and as needed, including regulatory items.
Follow policies for medication administration, transcription, and the MAR process.
Promote Loretto’s mission, values, vision, and strategic goals; treat others with dignity, professionalism, and kindness; and provide excellent customer service.
Maintain reliable attendance and work ethics, and attend required meetings and training sessions.
Comply with policies, procedures, codes of conduct, HIPAA, health and safety requirements, and role-related compliance and regulatory training requirements.
Perform other related duties as assigned.