RN Case Manager

Trinity Health•Wilmington, DE

12d•Hybrid

About The Position

The Nurse Case Manager is responsible for planning, coordination, implementation and evaluation of health care and social services to participants at the PACE program. Serves as the liaison between the interdisciplinary team (IDT), participants, caregivers and community agencies. This position typically requires no nights, weekends, or holidays, but includes administrative on-call requirements one night every other week on average (with stipend). It also requires regular travel to in-network hospitals or skilled nursing facilities as needed to coordinate care. The role will serve PACE programs in both Wilmington and Newark but will office out of the Wilmington program, with travel to other sites as needed.

Requirements

Graduate of an accredited nursing program with an active, unencumbered RN license and current CPR certification.
At least 2 years’ experience with geriatric populations.
Valid driver’s license and proof of insurance required.
Strong clinical skills, problem-solving ability, and accurate, thorough documentation practices.
Proficiency in Microsoft Office.
Superior written and verbal communication skills.
Ability to change and be flexible with work priorities.
Ability to adapt to changing priorities and work independently.
Strong interpersonal, organizational, customer service and problem-solving skills.
Up to 25% travel to local facilities required.

Nice To Haves

BSN preferred
EPIC knowledge preferred

Responsibilities

Attend required training and continuing education.
Participate in interdisciplinary team (IDT) assessments, care planning, and ongoing participant evaluations.
Communicate health status changes and coordinate 24-hour care delivery.
Serve as liaison among participants, caregivers, IDT, and community agencies.
Support Quality Assessment and Process Improvement (QAPI) initiatives.
Coordinate hospital discharges and communicate updates to families.
Conduct home visits to assess living conditions and support systems.
Maintain accurate participant records and documentation.
Educate and counsel participants and families; make referrals as needed.
Coordinate and manage participant care with clinicians and caregivers.
Assist with regulatory compliance, survey readiness, and correction plans.
Adhere to federal/state regulations and OSHA guidelines.
Participate in committees supporting program operations.
Provide on-call coverage and follow up on after-hours issues.