RN Case Manager

St. Paul's Senior Services•Chula Vista, CA

About The Position

San Diego’s St. Paul's PACE program (Program of All-Inclusive Care for the Elderly). This innovative program is for individuals 55 years or older, who are living with chronic illness, or disabilities and need coordinated medical care to continue living as independently as possible in their home and community. The healthcare teams at St. Paul’s PACE provide a hands-on approach coordinating medical, social, and home care services so individuals no longer need to manage their medical care alone. Job Summary: Under the direction and supervision of the Clinical Services Manager, the RN Case Manager is responsible for coordinating comprehensive participant care in collaboration with an interdisciplinary team. This role ensures timely assessments, medication management, care planning, and participant education in accordance with CMS guidelines and organizational standards. The nurse serves as a key clinical liaison between participants, families, PCCs, providers, pharmacies, and home care services to promote safe, effective, and continuous care.

Requirements

Education – Current California Registered Nurses License, CPR certification required.
Experience – A minimum of one year’s experience in working with the frail or elderly population is required.
Shall have either training or related experience in the job assigned.

Nice To Haves

IV Certification preferred.

Responsibilities

Performs the administration of medications, including oral, topical, intravenous, vaccinations and injectable forms in the clinic in accordance with nursing standards. Records all medications and treatments administered.
Coordinate comprehensive participant care in collaboration with the interdisciplinary team which includes attending IDT meetings and participating in Plans of Care meetings.
Conduct comprehensive initial, semi-annual, annual, and change-of-condition assessments in compliance with CMS guidelines. Coordinates with the interdisciplinary team to develop a comprehensive care plan for participants. Travel to the participant’s location as required.
Maintains participants’ medical record and fulfills CESD charting and reporting requirements. Minimally provision of Quarterly narrative nursing case management note, unless a participant’s condition requires a more frequent note, indicating participant’s progress toward achieving health goals.
Determine nursing level of care in accordance with regulations as delegated by Clinical Services Manager.
Case Management of participants on end-of-life services to complete initial admission visits.
Complete in-home visits for nursing services outside the scope of LVN In-home Service nurses.
Develop, update, and maintain accurate nursing care plans that reflect nursing services provided.
Manage medication-related processes including executing new orders, reordering medications, coordinating pre- and post-operative medications, coordinating pharmacy services and medication deliveries.
Communicate updates to Care Kinesis regarding participant contact information changes, including address updates.
Maintain and update participants’ Medicare Part A status, including completion and submission of 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.
Assist with utilization reduction by reviewing hospital documentation for discharge appropriateness and referring to the End-of-Life program when appropriate.
Collaborate with homecare team members to coordinate supplies, medications, and in-home nursing services.
Shall attend in-service education program, including orientation and skill training and continuing education.
Shall receive in-service training in first aid and in cardiopulmonary resuscitation within the first six months of employment.
Follows all St. Paul’s PACE Policies and Procedures and OSHA safety guidelines.
Maintains the confidentiality of all company procedures, results, and information about participants, clients, or families.
Practices Universal precautions and follows appropriate Infection Control procedures.
Maintains a safe working environment. Follows St. Paul’s PACE Safety Policies and Procedures.
Participates in and supports Quality Improvement initiatives.
Performs other duties as required or requested