Case Manager

Duties:

"Role Summary:

The Case Manager is a member of the Interdisciplinary Care Team Client (ICT) and will work in collaboration with the team to deliver and manage all aspects of participant care. The Case Manager will conduct required PACE assessments and develop and follow individualized participant Care Plans as well as address patient needs, communicate with participants and their families, advocate for participant needs to be met. In partnership with the Primary Care Provider, the Case Manager is responsible for delivering care in the center, in participant s homes, at skilled nursing facilities or any other type of short-term or long-term care setting, managing participant and family care needs.

Duties and Responsibilities:

-Take ownership of the outcomes and quality of care for their assigned participant panel, working directly and in tandem with the PCP, utilizing other clinic resources to function at the top of their license.

-Conduct in-clinic, at home, and virtual PACE required assessments (minimally every 6 months), educate participants and their support network on acute, chronic, and endstage conditions, perform urgent and routine virtual or in-person follow-up visits as determined by the participant s risk stratification and needs and as a direct extension to the PCP.

-Develop and implement a discipline specific plan of care (POC) in collaboration with the IDT, participants, families or POAs to ensure delivery of high quality, value-based, holistic, participant-centric, and compassionate care, capturing their assessments, findings, relevant information, plan and respective actions through their timely and compliant documents in EHR.

-Identify participants overt problems and needs, be able to determine priorities and appropriately escalate to the Primary Care Provider and collaborate effectively with other team members of IDT regarding these.

-Coordinate the care for select participants with highest level of complexity, including those at the hospital, ER, and skilled facility level of care with the Complex Care Team to ensure seamless transitions of care, participant satisfaction, and to prevent unfavorable outcomes, inappropriate utilization of resources, and unnecessary hospitalizations.

-In collaboration with the PCP, attend to Clinical Inbox, to ensure that orders are completed in a timely manner, test results and documents are reviewed, followed up on, and appropriate actions are taken, documented, and communicated with their participants.

-Perform and document ordered procedures and care in clinic or in the home when a home visit is required or deemed necessary, in accordance with Product of practice, as directed by PCP.

-Communicate participant changes to interdisciplinary team including, post-procedure or post discharge needs and any changes in level of care, condition, or functional status. pg. 1 20210920 Case Manager_RD

-Coordinate with Complex Care Team on participant discharges and transitions of care including post discharge/transition medication needs and facilitate transitions in and out of hospice and monitor monthly census with hospice agency.

-Review results from medical tests and evaluations and work with provider on timely responses to participants while ensuring appropriate documentation and follow up.

Skills:

"Required Skills & Experience:

-Minimum of two years of nursing experience in a clinical setting with a frail or elderly population.

-Nursing knowledge and skills necessary to treat frail, elderly participants and manage complex clinical situations.

-Highly motivated, self-directed, able to execute tasks in a quickly changing environment and make sound decisions in emergency situations.

-Excellent clinical, organizational and communication skills in settings with seniors, their families, and interdisciplinary team members.

-Multi-tasks to contribute toward projects as well as respective activities, timelines, and process improvement initiatives.

-Excellent organizational and communication skills.

-Ability to work independently with minimal supervision.

-Demonstrated ability to prioritize in a fast-paced environment.

-Experience and competency working with people from diverse backgrounds and cultures.

-Commitment to unlocking the full potential of our most vulnerable seniors.

Preferred Skills & Experience:

-Bilingual English/Spanish preferred. "-Absent the Clinic Supervisor, the Clinic Nurse or the Clinical Coordinator, provide support on specific and relevant tasks associated with these roles as needed in support of the clinic, the PCP and the delivery and coordination of participant care.

observations and implement nursing measures related to impending or associated problems.

-Act as a coordinator of care, on behalf of participants and with other health care personnel, with evaluation and follow up on patient care measures (i.e., dentures, glasses, personal care, procedures, labs, referrals, or transportation). "

Education:

Required Education:

-Graduate of an Accredited School of Nursing.

Preferred Education:

-N/A

Required Certifications & Licensure:

-Unencumbered RN License

-BLS

Preferred Certifications & Licensure:

-N/A