Lead RN Case Manager

Summary The Lead Registered Nurse Case Manager (RNCM) of the PACE Southeast Michigan (PACE SEMI) applies a systematic nursing approach that includes assessment, planning, implementation, and evaluation for frail elders with complex needs. The RN demonstrates a direct relationship between nursing interventions and participant outcomes, maintains clinical competence, and conducts effective patient teaching in prevention and treatment. The RN directs licensed and non‑professional nursing staff to coordinate care, enhances functional capacity, encourages autonomy, and ensures coordination of all nursing care. Specific Duties and Functions The RNCM assesses participants’ needs and plans appropriate nursing care during the Initial Intake Assessment and routine Re‑Evaluation Assessments. The RNCM collaborates with the participant, family, and the multidisciplinary team to develop and revise care plans, maximizes functional capacity, teaches and counsels participants or caregivers, implements preventive and rehabilitative programs, administers medications and treatments ordered by the physician/NP, and monitors participant responses. The RN notifies medical personnel of status changes, instructs participants/families on safe medication administration, and promotes medication compliance. The RNCM performs critical thinking for abnormal test results, provides comprehensive patient care with focus on the individual and family, follows hospital policies, leads professional and non‑professional staff, supervises home health aide services, evaluates and communicates outcomes, and participates in interdisciplinary and IDT meetings to refine care plans and measure responses. The RNCM maintains accurate records as per CSI policies, collects and documents PACE data, advocates for participants, upholds the Participant Bill of Rights, and contributes to high participant satisfaction. The RNCM may provide after‑hours on‑call medical assistance on a rotating basis, via phone triage or home visits; schedule requires a rotating on‑call shift. Additional Responsibilities for Lead RNCM Send out care plan calendar for the following month two weeks before the first of that month. Assign new participants to RNCMs and coordinate with lead Social Worker. Assign new participants to LPNs. Attend Lead RNCM/SW meetings. Attend NPO and/or provide business cards to all new participants. Attend IDT meetings and encourage other RNCMs to attend. Coordinate RNCM IDT coverage. Be prepared for last‑minute substitution to lead IDT. Support other RNCMs and LPNs. Train new RNCMs. Perform all other RNCM responsibilities. Knowledge, Skills, and Abilities Must be a Registered Nurse with current Michigan licensure; BSN preferred. Participates in annual mandatory in‑service training (infection control, TB testing, safety training, BLS training). Assumes responsibility for ongoing self‑development through continuing education and serves as a role model. Maintains a current Michigan driver’s license with an acceptable driving record. Possesses strong interpersonal and interdepartmental relationship skills. Applies principles of adult learning in planning and implementing educational activities. Leads and directs licensed and non‑professional nursing staff. Participates in and facilitates quality assurance projects and nursing research studies. Reviews current periodical literature relevant to nursing practice and the PACE model of care. Ensures adherence to departmental and external standards by attending professional meetings, reviewing national standards, and meeting CMS competencies before independent work. Has at least one year of experience with a frail or elderly population. Working Conditions The RNCM works in the participant’s home, an uncontrolled environment that may expose the RNCM to infectious materials, blood‑borne pathogens, and hazardous waste. The RNCM must be medically cleared for communicable diseases and have all immunizations up‑to‑date before direct contact. Driving within the PACE SEMI catchment area is required, with exposure to extreme temperatures. Reliable transportation is necessary on a daily basis. Frequent walking, bending, lifting of 40 pounds or more, and other physical demands may be required. Schedule Rotating on‑call shift required. #J-18808-Ljbffr PACE Southeast Michigan