RN Case Manager

St Pauls Senior Services•SAN DIEGO, CA

About The Position

The RN Case Manager coordinates comprehensive participant care under the direction and supervision of the Clinical Services Manager, working with an interdisciplinary team. The role ensures timely assessments, medication management, care planning, and participant education in accordance with CMS guidelines and organizational standards. The nurse serves as a clinical liaison among participants, families, PCCs, providers, pharmacies, and home care services to support safe, effective, and continuous care. This is a full-time position with a typical schedule of Monday through Friday, 8:00 AM to 4:30 PM. The position includes clinic medication administration and participant visits at their locations as required.

Requirements

Current California Registered Nurse license.
CPR certification.
At least one year of experience working with the frail or elderly population.
Training or related experience in the job assigned.
Valid driver’s license and reliable transportation.

Nice To Haves

IV certification preferred.

Responsibilities

Administer medications and treatments in the clinic, including oral, topical, intravenous, vaccinations, and injectable forms, and document those administered.
Coordinate participant care with the interdisciplinary team, attend IDT meetings, and participate in Plans of Care meetings.
Conduct comprehensive initial, semi-annual, annual, and change-of-condition assessments in compliance with CMS guidelines.
Collaborate with the interdisciplinary team to develop comprehensive participant care plans.
Travel to participant locations as required and complete in-home nursing visits outside the scope of LVN In-home Service nurses.
Maintain participant medical records and fulfill CESD charting and reporting requirements, including at least quarterly narrative nursing case management notes unless more frequent documentation is needed.
Determine nursing level of care in accordance with regulations as delegated by the Clinical Services Manager.
Provide case management for participants receiving end-of-life services, including initial admission visits.
Develop, update, and maintain accurate nursing care plans reflecting nursing services provided.
Manage medication-related processes, including executing new orders, reordering medications, coordinating pre- and post-operative medications, and coordinating pharmacy services and medication deliveries.
Communicate participant contact information changes, including address updates, to Care Kinesis.
Maintain and update participants’ Medicare Part A status, including completing and submitting the Part A Notification Form.
Complete monthly medication verification and reconciliation for participants receiving medication management services.
Facilitate discharge planning from hospitals or skilled nursing facilities, including management of new prescriptions, ordering DMW, pharmacy coordination, and medication delivery.
Support utilization reduction by reviewing hospital documentation for discharge appropriateness and referring participants to the End-of-Life program when appropriate.
Collaborate with homecare team members to coordinate supplies, medications, and in-home nursing services.
Attend orientation, skill training, in-service education, and continuing education; receive first aid and cardiopulmonary resuscitation in-service training within the first six months of employment.
Follow St. Paul’s PACE policies and procedures and OSHA safety guidelines; maintain confidentiality, practice universal precautions and infection control, and maintain a safe working environment.
Participate in and support Quality Improvement initiatives.
Perform other duties as required or requested.