RN Care Manager - Hourly- Bilingual (Hmong)

About the role

The Registered Nurse Care Manager is responsible for assessing the care needs of participants, providing nursing and healthcare interventions, and evaluating outcomes of care on an ongoing basis. In collaboration with the interdisciplinary team (IDT), you will develop plans of care to meet participants’ needs, delegate tasks to clinic, center, and homecare aides, and collaborate with primary care providers and other IDT members. Care is provided in the clinic, center, and participants’ homes as needed.

Responsibilities

• Provide high-quality clinical care as a member of the PACE interdisciplinary team (IDT).
• Deliver nursing care in the center, clinic, contracted facilities, and participants’ homes according to each participant’s plan of care.
• Participate in a 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.
• Monitor participants’ acute and chronic care needs in all settings; provide coordination and direct care to promote continued community care or optimal institutional care (e.g., Assisted Living, Nursing Home, Hospital).
• Ensure timely follow-up by providers on specialist visits; assist with obtaining specialist reports, facility documentation, and labs as needed.
• Reconcile facility Medication Administration Records (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.
• Review and revise goals and approaches to participants’ care in coordination with the participant, family, caregiver, and interdisciplinary team.
• Collaborate with the IDT to develop and implement comprehensive plans of care.
• Develop and maintain positive relationships with co-workers, participants, their families, and community members.
• Participate in all interdisciplinary team meetings; assist team members in understanding participants’ significant nursing and self-care needs.
• Support Occupational Therapy as a backup to performing Home Care Coordinator duties on the IDT as needed.
• Perform duties of other IDT members based on professional licensing, competencies, and experience as needed.
• Actively participate in utilization review meetings and quality improvement projects.
• Evaluate the competence of Certified Nursing Assistants (CNAs) and Home Care Aides; delegate tasks and duties as indicated.
• Participate in family meetings, staff meetings, in-service training, and orientation programs as required.
• Follow all PACE Program Policies and Procedures and OSHA safety guidelines.
• Protect privacy and maintain confidentiality of all company procedures and participant information.
• Practice standard precautions and follow PACE Program Infection Control protocols.
• Perform other duties as required or requested.

Requirements

• State RN License required.
• BLS certification required (must obtain within 90 days of employment).
• 1 year of experience providing care as an RN required.
• 1 year of experience working with a frail or elderly population preferred (training provided if not present).
• Experience in home care, long-term care, and/or managed care preferred.
• Bilingual with fluency in Hmong strongly preferred.
• Bachelor of Science in Nursing Degree preferred.
• Must have reliable transportation, a valid driver’s license, and the minimum state-required liability auto insurance.
• Must be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.

Benefits

• Competitive compensation.
• Medical and dental coverage.
• Generous paid time off.
• 401K with match (begins after one year of employment).
• Life insurance.
• Tuition reimbursement.
• Flexible Spending Account.
• Employee Assistance Program.

Why work with us

At BoldAge PACE, we prioritize a people-first environment, making what is important to those we serve important to us. You’ll have the opportunity to enhance the quality of life for seniors, access professional growth through training and career development, and be part of a mission-driven team dedicated to helping older adults live meaningful, independent lives at home with grace and dignity.