Employment Type:

Shift:

Description:

POSITION PURPOSE
The Nurse Case Manager is responsible for planning coordination implementation and evaluation of health care andsocial services to participants at the PACE program. Serves as the liaison between the interdisciplinary team (IDT)participants caregivers and community agencies.

ESSENTIAL FUNCTIONS
1. Know understand incorporate and demonstrate the Mission Vision Values and Guiding Behaviors of TrinityHealth and Trinity Health PACE (TH PACE) in behaviors practices and decisions.
2. Consistently demonstrate (leads by example) TH PACE Values to all internal and external customers(participants visitors volunteers and colleagues.) Create and maintain an atmosphere of warmth propagating acalm environment throughout the office.
3. Execute assignments in a culture that is shared and collaborative across all divisions within TH PACE.
4. Reflects the skills knowledge and abilities serving in the role of a leader. Define and share a strategy and vision;align resources toward achievement of organization results; grow and sustain the organization; identify lead and
embrace change.
5. Establish and/or maintain as a member of the leadership team a plan to achieve operating goals.
6. Promote and maintain collaborative relationships with managers peers direct reports and customers byeffectively fostering a team environment building consensus and resolving conflicts.
7. Maintain department budget place orders for equipment and supplies as necessary. Identify financialvulnerabilities and make cost reduction recommendations as needed.
8. Evaluate develop mentor coach counsel and discipline department staff. Supports other personnel from otherdepartments through coaching and mentoring to help achieve optimum standard of excellence. Addresses issues
of concern through courageous conversation and notifies department manager of any interactions requiringattention.
9. Maintains a working knowledge of applicable Federal State and local laws and regulations TH PACE CorporateIntegrity Program Code of Ethics as well as other policies and procedures in order to ensure adherence in a
manner that reflects honest ethical and professional behavior.
10. In light of a disaster will know your disaster recovery crisis management and business continuity plans and act within your role that is developed within the business continuity plan. Which may include working at another
location remotely from home and maintaining constant contact with key personnel.
11. Attend and participate in scheduled training in-service training mandatory annual in-service training andeducational classes as required/needed.
12. Participate as a member of the interdisciplinary team (IDT) including completion of initial medical historyphysical exam and functional nursing assessments of each new participant and semi-annual annual and
unscheduled assessments: communicate changes in participant health or functional status to the interdisciplinaryteam members and participate in development of the plan of care and coordination for 24-hour care delivery.
13. Acts as liaison between the interdisciplinary team (IDT) participants caregivers and community agencies.
14. Actively serves on the Quality Assessment and Process Improvement (QAPI) Committee if required. Involved inthe development and implementation of QAPI activities.
15. Coordinate hospital discharges in conjunction with the interdisciplinary team (IDT) and attending updates to family or caregivers as needed.
16. Perform home visits as needed to assess living environment and support system.
17. Maintain current written/electronic records and documents related to participant care.
18. Communicate counsels and guides participants and families regarding service needs and concerns; makes referralsas appropriate.
19. Manage and facilitate coordination and collaboration of participant care will all clinicians and for identification of need and utilization of clinical services.
20. Actively participates in the coordination of efforts towards survey preparedness. When necessary contribute tothe plan of correction for department deficiencies.
21. Responsible for adherence to all regulations both federal and state which govern the operations of a PACEorganization and a licensed adult day care center. Follow Occupational Safety and Health Administration (OSHA)
guidelines.
22. Counsel and educate participants families and staff on health-related topics.
23. Actively serves on various committees that support the daily operations of the program.
24. Provide on-call coverage during center hours of non-operation if applicable.
25. Communicate with weekend and afterhours on-call staff following up on issues as necessary.
26. Maintain confidentiality of participant information.

Our Commitment

Rooted in our Mission and Core Values we honor the dignity of every person and recognize the unique perspectives experiences and talents each colleague brings. By finding common ground and embracing our differences we grow stronger together and deliver more compassionate person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin disability veteran status or any other status protected by federal state or local law.