RN Care Manager PACE - FT - Day - LIFE Bordentown NJ

Capital Health (US)•Life, TN

13d•$40 - $54•Hybrid

About The Position

This role's function also involves home visits to participants of the LIFE program. Assures that participant care is organized, coordinated, and carried out using the Interdisciplinary Team process by competent staff in compliance with established budget; oversees the effective delivery of participant care across the continuum of care. Collaborates with Primary Care Physicians and Interdisciplinary team on participant care issues. Assesses the quality of care regularly through direct observation and supervision; assures that quality metrics perform to the target level. Reviews the plans of care for and with participants and evaluates implementation on a regular basis to assure the delivery of safe and appropriate care; intervenes with staff to improve care as indicated. Assures that care is documented completely and accurately. Works with staff to evaluate and determine LOC needs and changes. Completes and documents information accurately prior to participant transition of care. Works collaboratively with other agencies to discharge participants to appropriate level of care. Communicates with each discipline involved in care regarding that discipline’s assessment and plan of care through the transition and assures there is a complete, integrated plan of care reflecting transition of care changes. Assures all needed services and supplies are in place, authorized and appropriately documented. Prevents gaps in care, service, supplies or participant well-being through effective communication. Makes routine face to face contact with contracted facilities and reinforces those visits through appropriate follow up by phone or electronic means. Coordinates quarterly (at minimum) meetings with IDT members and contracted facility members at the facility. Perform quarterly reviews of contracted facilities plans of care. Assures they are accurate, current and appropriately integrated into the LIFE Care Plan (and vice versa). Assures that participant issues involving contracted facilities are communicated to all appropriate parties, documented and resolved. Participates in resolution of any facility related grievances as requested (along with appropriate LIFE and facility personnel). Appropriately identifies issues that require inclusion of higher levels of authority to ensure a thorough resolution. Obtains necessary information and resources for resolution of new or acute complex issues identified by the IDT. Supports the IDT to resolve acute complex issues by coordinating and communicating with needed resources. Assures that needs of participant and family/caregivers are addressed and integrated into resolution. Attends morning meeting for the assigned team (or provides coverage to other teams when needed). Is responsible for daily subgroup/huddle meetings to address coordination of care for participants, Actively participates in the Quality Improvement activities of the PACE Program by identifying issues, proactively addressing issues and participating in PI teams and committees. Performs other duties as assigned.

Requirements

BSN required.
4 years of nursing experience required.
Drivers License
Registered Nurse - NJ

Nice To Haves

Prior home care experience preferred.
Prior management experience preferred.
Demonstrated strong leadership skills, preferably in an interdisciplinary model of care.
Experience as a case manager, care coordinator or discharge planner preferred.

Responsibilities

Organize, coordinate, and carry out participant care using the Interdisciplinary Team process.
Oversee the effective delivery of participant care across the continuum of care.
Collaborate with Primary Care Physicians and Interdisciplinary team on participant care issues.
Assess the quality of care regularly through direct observation and supervision.
Review plans of care with participants and evaluate implementation.
Ensure care is documented completely and accurately.
Evaluate and determine LOC needs and changes with staff.
Complete and document information accurately prior to participant transition of care.
Collaborate with other agencies to discharge participants to appropriate level of care.
Communicate with each discipline involved in care regarding assessments and plans of care.
Ensure all needed services and supplies are in place, authorized, and appropriately documented.
Prevent gaps in care, service, supplies, or participant well-being through effective communication.
Make routine face-to-face contact with contracted facilities and follow up appropriately.
Coordinate quarterly meetings with IDT members and contracted facility members.
Perform quarterly reviews of contracted facilities' plans of care.
Ensure participant issues involving contracted facilities are communicated, documented, and resolved.
Participate in the resolution of facility-related grievances.
Obtain necessary information and resources for resolution of new or acute complex issues.
Support the IDT to resolve acute complex issues by coordinating and communicating with needed resources.
Ensure the needs of participants and families/caregivers are addressed and integrated into resolution.
Attend morning meetings for the assigned team or provide coverage to other teams.
Conduct daily subgroup/huddle meetings to address coordination of care for participants.
Actively participate in Quality Improvement activities of the PACE Program.