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

About the role

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.

Key Responsibilities

• Caseload & Panel Management
• 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.
• Participant Visits
• 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.
• Assess participant acuity and adjust visit frequency and setting based on participant acuity, care plan requirements, direction from/collaboration with PCP and clinical judgment.
• Assessments & Care Planning
• 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.
• Chronic Care Management
• 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.
• Interdisciplinary Team Collaboration
• 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.
• Care Coordination & Transitions
• 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.
• Documentation & Compliance
• 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.
• Other Duties
• Perform other duties as assigned by JVSC leadership.

Benefits Overview

• Medical and Prescription Drug Coverage: Three comprehensive plan options (Buy-up, Base, and High Deductible) through UnitedHealthcare's Choice Plus network, covering various deductibles and out-of-pocket limits.
• Health Savings Account (HSA): Available for employees in the High Deductible Plan with employer contributions and tax advantages.
• Flexible Spending Account (FSA): Options for both healthcare and dependent care FSAs, allowing pre-tax contributions for qualified expenses.
• Dental and Vision Coverage: Dental insurance through Cigna’s DPPO network and vision coverage through EyeMed’s Insight network.
• Retirement Plan: Pre-tax and Roth 403(b) retirement plans with a 5% employer match starting after 30 days of employment.
• Life and Disability Insurance: Basic Life and AD&D insurance provided at no cost, with the option to purchase additional coverage.
• Employee Assistance Program (EAP): Free confidential support for personal and professional challenges, including counseling and crisis intervention.
• Additional Voluntary Benefits: Options for critical illness, accident, hospital care, and pet insurance through MetLife.

Pay

Pay on Demand Available.

Schedule

Nine paid holidays per year.

Health Requirements

All employees are required to provide proof of vaccination for Flu, Hepatitis B and Tuberculosis (TB) as part of our commitment to maintaining a safe and healthy workplace.

Application Process

Interested applicants should submit a resume and cover letter through the JVH career portal at Careers & Education - Jordan Valley. Applications will be accepted on a rolling basis until the position is filled.