PACE RN Case Manager
PACE RN Case Manager
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Job Description
Join the Team Voted Best Place to Work in North County!
Why Work for Gary and Mary West PACE
Because you desire work/life balance and have a passion to make a difference in the lives of North County seniors and their families!
You will receive generous pay and a benefits program focused on your health and wellness that includes 11 paid holidays 13 days of PTO plus 5 days of sick time. a 5% employer-match to our 403b retirement program and no on-call time.
Because we encourage professional development and support all staff to expand their skillset providing an annual education allowance.
You will be part of a distinct company culture where work feels like family and collaborate with a multi-disciplinary team environment where you are appreciated and valued.
Come do your best work where your contribution matters!
About PACE:
Philanthropists Gary and Mary West founded West Health with the mission of enabling seniors to successfully age in place with access to high-quality affordable health and support services that preserve and protect their dignity quality of life and independence. The Gary and Mary West PACE (Program of All-inclusive Care for the Elderly) affiliated with West Health () is a non-profit that delivers medical social and behavioral services to the frail elderly to the North County of San Diego. This PACE center is entrepreneurial in nature and focuses on innovations and bringing new processes to the traditional PACE environment.
Were looking for passionate healthcare providers who want to be part of a team dedicated to enable seniors to live in their communities as independently as possible by providing compassionate comprehensive health and supportive care.
One Team One Mission
Position Summary
The Gary and Mary West PACE (GMWP) RN Case Manager provides case management for assigned participants. Utilizes clinical expertise communication and problem-solving skills to achieve optimal clinical and resource outcomes. Promotes quality of care by minimizing fragmentation maximizing coordination and facilitating participant movement through the health care organization. Performs patient needs assessments upon admission and at regular intervals facilitating referrals and providing linkages to health wellness and post-acute care resources across the health care continuum. Promotes interdisciplinary collaboration and teamwork to progress the plan of care and discharge plan. Promotes appropriate length of stay resource management and care transitions to the next level of care. Must comply with all federal and state regulations surrounding the discharge process.
Essential Functions:
- Performs daily coordination of care with inpatient hospital and/or the RCFE staffing.
- Actively assists providers hospital and RCFE staff in the care management of affected PACE participants by establishing and facilitating regular and ongoing channels of communication.
- Assesses participants for medical necessity and level of care appropriateness while facilitating level of care transitions i.e. hospital to home/RCFE or home to RCFE.
- Collaborates with providers other members of the interdisciplinary health care team participants and caregivers in the development implementation and documentation of appropriate individualized plans of care to ensure continuity quality and appropriateness of resources.
- Participates in the interdisciplinary team to formulate Plans of Care for PACE participants as well as in other interdisciplinary team settings that plan coordinate and monitor the care of PACE participants in institutionalized settings.
- Recommends alternative levels of care and ensures compliance with federal state and local requirements.
- Ensures PACE plan of care is communicated and adhered to by the contracted RCFEs where PACE participants reside through regularly established joint conference meetings
- Provides or coordinates PACE or Participant-related education to the contracted RCFEs.
- Acts as the liaison between PACE and contracted RCFE facilities to assure all appropriate and essential services are implemented timely and efficiently for PACE participants.
- Oversees the coordination of specialty appointment Day Center and other scheduling needs for the participants residing in RCFEs.
- Conduct regular visits (as appropriate) to contracted RCFEs where PACE participants are residing to facilitate care-coordination.
- Provides general nursing care to participants as needed including administering prescribed medications and treatments.
- Observes and reports participants condition and response to medications treatments and other interventions to the IDT.
- Documents all necessary information in the EMR and maintains participant medical record(s) per PACE policies and procedures.
- Develops implements and maintains a current nursing care plan for participants residing in RCFEs in cooperation with the Clinic Nurse and the IDT.
- Maintains accurate medical records from hospitalizations and any other transitions of care for participants residing in RCFEs including the management of documents of in hospital stay and examination results for participant records.
- Communicates effectively with the participants interdisciplinary team family members and caregivers and others
- Other duties as assigned.
Education and Certification:
- Graduate of an accredited school of nursing; Bachelor of Science (BSN)preferred.
- Unencumbered California Registered Nurse (RN)License.
- Current Basic Life Support (BLS) / First Aid Certification required
- Current Drivers license and proof of auto insurance.
Skills & Experience:
- Minimum of two years 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.
- Experience and competency working with people from diverse backgrounds.
- Commitment to unlocking the full potential of our most vulnerable seniors.
- Bilingual Spanish-English preferred.
Medical Clearance:
Employees must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
Job offers are contingent upon a successful pre-employment drug screen background check and physical assessment.
Gary and Mary West PACE provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race color religion sex national origin pregnancy military and veteran status age physical and mental disability genetic characteristics gender gender identity gender expression or sexual orientation or any other considerations made unlawful by applicable state or local laws.
Required Experience:
Manager
Employment Type
Full-Time
