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.

Responsibilities

• 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.
• 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.
• Career 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.
• 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.
• 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.
• 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.
• Perform other duties as assigned by JVSC leadership.

  Qualifications

  • Graduate of an accredited school of nursing (Associate's or Bachelor's degree in Nursing required).
  • Current, unrestricted RN Licensure in state of practice in good standing, received from a qualified, accredited school of nursing.
  • Current BLS Certification required within 90 days of hire.
  • Either one year of experience working with a frail or elderly population or, in the absence of such experience, receive appropriate training from the JVSC on working with a frail or elderly population upon hire.
  • Valid driver's license and reliable transportation required for home and facility visits.
  • Bachelor of Science in Nursing (BSN) preferred.
  • Minimum of 2 years of clinical nursing experience required; geriatric, home health, case management, or community-based care experience strongly preferred.
  • Prior experience with frail or elderly populations, chronic disease management, or interdisciplinary care models preferred.
  • PACE program experience a plus.