RN Case Manager, Jordan Valley Senior Care (JVSC) PACE

Jordan Valley Health•Springfield, MO

7d•Hybrid

About The Position

The RN Case Manager is a core member of the PACE Interdisciplinary Team (IDT), responsible for the ongoing clinical management of an assigned participant caseload/panel. This role coordinates and delivers care across home, clinic, and facility settings, manages comprehensive assessments, and leads the development and execution of individualized care plans. The RN Case Manager serves as the primary clinical point of contact for a defined panel of participants, ensuring continuity of care, chronic condition management, and timely response to changes in participant status, in accordance with PACE regulatory and quality standards.

Requirements

Graduate of an accredited school of nursing (Associate's or Bachelor's degree in Nursing required)
Current, unrestricted RN Licensure in state of practice in good standing, received from a qualified, accredited school of nursing
Current BLS Certification required within 90 days of hire.
Either one year of experience working with a frail or elderly population or, in the absence of such experience, receive appropriate training from the JVSC on working with a frail or elderly population upon hire.
Valid driver's license and reliable transportation required for home and facility visits.
Minimum of 2 years of clinical nursing experience required

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred
Geriatric, home health, case management, or community-based care experience strongly preferred.
Prior experience with frail or elderly populations, chronic disease management, or interdisciplinary care models preferred.
PACE program experience a plus.

Responsibilities

Manage a defined caseload/panel of participants, serving as their primary nursing point of contact across the care continuum.
Maintain ongoing clinical accountability for panel participants, including tracking status changes, care needs, supplies, medications, and follow-up items across care settings.
Prioritize and triage panel workload based on acuity, urgency, and scheduled care requirements.
Conduct a regular mix of home visits, clinic-based visits, and facility visits (e.g., skilled nursing, assisted living, hospital) to assess and manage participant care.
Adjust visit frequency and setting based on participant acuity, care plan requirements, direction from/collaboration with PCP and clinical judgment.
Coordinate visit scheduling with the transportation, home care, and IDT teams to ensure timely access to care.
Complete comprehensive initial, semi-annual, and status change assessments in accordance with PACE and CMS/state requirements.
Develop, implement, and update individualized care plans in collaboration with the participant, caregivers, and IDT.
Identify and document changes in condition, functional status, and risk factors; initiate care plan revisions as needed.
Ensure assessments and care plans are completed within required regulatory timeframes and accurately documented in the EMR.
Monitor and manage participants with chronic conditions (e.g., diabetes, CHF, COPD, dementia) to prevent avoidable decline, ER visits, and hospitalizations.
Provide participant and caregiver education on disease management, medication adherence, and self-management strategies.
Coordinate chronic care needs with primary care providers, specialists, and ancillary services.
Actively participate in IDT meetings, presenting panel updates, assessment findings, and care plan changes.
Communicate and collaborate with physicians, social workers, therapists, dietitians, and other IDT members to ensure coordinated, person-centered care.
Serve as a clinical liaison between participants/caregivers and the IDT.
Coordinate care transitions across settings (hospital, skilled nursing facility, home) to ensure continuity and safety.
Follow up on hospital and facility discharges to confirm timely implementation of updated care plans.
Coordinate referrals to specialists, ancillary services, and community resources as needed.
Participate in an on-call rotation with other clinical and administrative staff, including potential for phone calls and home/facility visits.
Maintain accurate, timely, and complete clinical documentation in the electronic medical record.
Ensure compliance with all applicable federal, state, and PACE program regulations, as well as organizational policies.
Support quality improvement initiatives and participate in audits, chart reviews, and regulatory surveys as needed.
Promote the education and development of students, interns, residents, apprentices, and other new staff by sharing expertise, responding to questions, and fostering a positive and supportive learning environment.
Perform other duties as assigned by JVSC leadership.