Registered Nurse Case Manager

About the role

THIS ASSIGNMENT ENDS DECEMBER 31, 2026.

Responsibilities

• Assessing participants physical and mental wellness, needs, preferences and abilities, and developing plans to improve.
• Conducting Home Care Nursing assessments to determine the nursing, personal care and equipment needs in the home, preferences and goals of the participants and actively participating in Interdisciplinary Team (IDT) meetings to develop participant care plans.
• Delivering and documenting home care nursing interventions as agreed upon in the participants’ care plans including but not limited to maintaining a healthy and safe environment, promptly and accurately responding to physician orders, and correctly administering medications and performing ordered tests and treatments.
• Providing health education and counseling to participants and caregivers experiencing chronic conditions and end-of-life issues.
• Participating in end-of-life care coordination and support.
• Working with the PACE Providers and other members of the IDT to manage smooth care transitions between settings (hospitals, skilled nursing facilities, home, etc.) upon proper endorsement of the Community Liaison upon discharge from acute hospital.
• Evaluating participants’ progress periodically and making adjustments as needed.
• Facilitating integration of new participants into the Innovative Integrated Health care delivery system, including medication, immunizations, routine monitoring of chronic problems, and nursing care plan development.
• Collaborate with Intake department and Care Coordination Group in supporting newly enrolled participants into the program and their continued needs.
• Developing and implementing Quality Improvement activities; evaluating overall effectiveness of the center, implementing change and quality improvement as needed.
• Providing phlebotomy services in the participants' home and/or clinic as ordered by the PCP.
• Cooking with outside contracted service providers, including hospitals, nursing facilities, assisted living facilities, lab, oxygen, etc.
• Communicating with Community Liaison and after-hours on-call staff, following up on issues, as necessary.
• Reviewing participant medical records to ensure timely and accurate clinic staff documentation.
• Supervising clinic staff’s administration of prescribed medications and treatments in accordance with nursing standards.
• As liaison with primary care provider in the event of an episodic illness; assisting in coordinating services provided by primary care provider.
• Timely and accurate completion of Root Cause Analysis (RCA) reports, Incident reporting and discussing with Care team group for follow up and/or interventions needed to prevent recurrence.

Requirements

• Broad knowledge base of physical, mental, and social needs of the frail elderly population.
• Knowledge of medical equipment and instruments.
• Knowledge of common safety hazards and precautions to establish a safe work environment.
• Experience in physical assessment and triaging.
• Skilled in identifying problems and recommending solutions.
• Able to effectively prepare and maintain records, write reports, and respond to correspondence.
• Clinical competency in home health care, effective care planning, and utilization management.
• Able to react calmly and effectively in emergency situations.
• Able to establish and maintain effective working relationships with participants, medical staff, staff members, and family caregivers in a pleasant, patient, and professional manner.
• Well organized, dependable, flexible, and resourceful.
• Effective oral and written communication skills.
• Computer skills required.

Qualifications

• Minimum of three (3) years of health care experience with emphasis in geriatrics.
• Minimum of one (1) year of documented experience working with a frail or elderly population.
• Minimum of one (1) year prior professional nursing experience.
• Graduate of accredited nursing program.
• Current California Registered Nurses license.
• CPR certification with First Aid Certification.
• Bachelor of Science in Nursing preferred.
• Medically cleared for communicable diseases and has all immunizations up-to-date before engaging in direct participant contact.