RN Care Manager

Summary

The RN Care Manager at BoldAge PACE is responsible for assessing the care needs of participants, providing nursing and healthcare interventions, and evaluating outcomes of care. They collaborate with the interdisciplinary team to develop plans of care and delegate tasks to clinic, center, and homecare aides. They also provide care to participants in various settings and communicate with the primary care provider and other members of the IDT.

Essential Duties and Responsibilities

• Provide high quality clinical care and serve as a member of the PACE interdisciplinary team (IDT).
• Provide nursing care in the center, clinic, contracted facilities, and participants' homes according to each participant's plan of care.
• Participate in 24/7 "on-call" process for triage of participants and their needs.
• Assess, plan, and coordinate participants' home care services.
• Provide input to the IDT in developing home care plan interventions.
• Maintain and monitor participants' acute and chronic care needs in all settings.
• Ensure timely follow-up by providers on specialist visits and assist with obtaining specialist reports, facility documentation, and labs if needed.
• Reconcile facility MARs for your assigned panel of participants monthly to ensure accuracy and medication adherence, notify provider of any discrepancies.
• Notify participants of normal test results.
• Complete timely and accurate nursing assessments in accordance with policies and regulatory requirements.
• Implement nursing-related care plan interventions.
• Teach participants, caregivers and families about self-care, medications, healthy lifestyles, infection control and safety to promote optimal health and safety.
• Review and revise goals and approaches to participants' care in coordination with participant, family, caregiver and interdisciplinary team.
• Collaborate with the interdisciplinary team to develop and implement comprehensive plans of care for participants.
• Develop and maintain positive relationships and communication with co-workers, participants and their families/significant others, and members of the community.
• Assist the interdisciplinary team members in understanding the significant nursing, self-care and functional needs related to the participant's health problems.
• Support OT as a backup to performing the duties of Home Care Coordinator on the IDT as needed/when assigned.
• May perform the duties of other IDT members based on professional licensing, competencies, and experience as needed.
• Participate in utilization review meetings and quality improvement projects/meetings.
• Evaluate the competence of CNAs and Home Care Aides and delegate tasks and duties to them as indicated.
• Absent from family meetings, staff meetings, in-service and training and orientation programs as required.
• Follows all PACE Program Policies and Procedures and Occupational Safety and Health Administration (OSHA) safety guidelines.
• Protects privacy and maintains confidentiality of all company procedures and information about employees, participants and families.
• Practices standard precautions and follows PACE Program Infection Control protocols.

Experience, Education and Certifications

• Bachelor of Science in Nursing Degree preferred.
• State RN License required **NJ: Licensed by the New Jersey State Board of Nursing.
• BLS required (have within 90 days of employment).
• 1 year of experience working with a frail or elderly population preferred. Training will be provided upon hiring (If applicable for the role).
• Experience in home care, long-term care and/or managed care preferred.
• 1 year experience providing care as an RN required.

Pre-Employment Requirements

• Must have reliable transportation, a valid driver's license, and the minimum state required liability auto insurance.
• Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.
• Pass a comprehensive criminal background check that may include, but is not limited to, federal and state Medicare/Medicaid exclusion lists, criminal history, education verification, license verification, reference check, and drug screen.
• BoldAge PACE provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.