Mobile IDT - Registered Nurse Case Manager

SUMMARY The Mobile IDT – Registered Nurse Case Manager (RNCM) of PACE Southeast Michigan (PACE SEMI) utilizes a systematic approach to nursing practice which incorporates all aspects of the nursing process including assessment, planning, implementation and evaluation of frail elders with complex needs. The Mobile IDT – Registered Nurse Case Manager demonstrates a direct relationship between nursing interventions and participant outcomes, demonstrates clinical competence and engages in effective patient teaching in areas of prevention as well as treatment. The Mobile IDT – Registered Nurse Case Manager effectively leads or directs licensed and non‑professional nursing staff in the coordinated delivery of care to participants of the PACE Southeast Michigan program. The focus of care is one that enhances functional capacity, encouraging autonomy in all aspects of care, and assures coordination of all nursing care. RESPONSIBILITIES Mobile 100% mobile; schedules and maintains own calendar. Assesses participants’ needs and plans appropriate nursing care upon Initial Intake Assessment and routine Re‑Evaluation Assessments. Collaborates with the participant, the family, and all members of the multidisciplinary team to develop the participant’s plan of care. Maximizes the participant’s functional capacity by encouraging autonomy in all aspects of care. Teaches, supervises, and counsels the participant or caregiver regarding nursing care needs and other related problems. Uses adult learning principles to plan and implement educational information for participants, caregivers, or family members. Initiates preventative and rehabilitative procedures or programs as appropriate for participants’ care and safety. Administers medications and treatments as ordered by physician/NP, monitors participant’s response, and notifies appropriate medical personnel of status changes. Demonstrates knowledge of medications administered and instructs participant/family in safe home medication administration. Encourages compliance with medication regimen. Has experience with phlebotomy and wound care; demonstrates competency with PIC lines and sterile dressing changes. Recognizes abnormal test results and applies critical thinking when gathering data, planning, and implementing care. Provides safe total patient care to participants with complex health problems. Maintains nursing practice standards and follows hospital policies/procedures for care delivery and medication administration. Leads and monitors licensed and other professional and non‑professional staff; provides monthly supervision and documentation of home health aide services. Evaluates participant outcomes and progress toward care plan objectives; communicates information among multidisciplinary team members. Collaborates with the interdisciplinary team to revise care plans based on changes in participants’ status and initiates consistent actions. Participates with patients, families, and team members to evaluate and measure response to nursing care and teaching interventions; documents outcomes at every scheduled review. Maintains accurate and timely records of participants’ functional/health status, progress toward plan outcomes, revisions, and care given per CSI policies. Participates in the collection and documentation of PACE information data. Advocates on behalf of the participant; resolves concerns or issues. Understands and promotes the Participant Bill of Rights, working to achieve high satisfaction levels. Provides after‑hours on‑call medical assistance on a rotating basis via phone triage or after‑hours home visits; rotating on‑call shift required. Performs other duties assigned by the leader. QUALIFICATIONS Registered nurse with a current Michigan licensure; BSN preferred. Participates annually in mandatory in‑service training and screening: infection control, TB testing, safety training, BLS training. Assumes responsibility for self‑development through continuing education; promotes professional behavior and growth. Holds a current Michigan driver’s license and maintains an acceptable driving record. Can establish and maintain interpersonal and interdepartmental relationships. Can apply principles of adult learning in planning and implementing educational activities. Can lead and direct other licensed and non‑professional nursing staff in care delivery. Participates in and/or facilitates quality assurance projects. Assists with the implementation of nursing research studies and reviews periodical literature relevant to nursing and the PACE model of care. Ensures adherence to departmental and external standards; attends professional meetings/committees. Meets standardized CMS competencies before working independently. Has at least one (1) year of experience with a frail or elderly population. WORKING CONDITIONS Works in the participant’s home, which is an uncontrolled environment. May be exposed to potentially infectious materials, blood‑borne disease pathogens, and hazardous waste; must be medically cleared for communicable diseases and have all immunizations up to date. Driving is required within PACE SEMI catchment area, with possible exposure to extreme temperatures; must have reliable transportation available daily. Frequent walking, bending, and lifting of forty (40) pounds or more may be required in the performance of duties. #J-18808-Ljbffr PACE Southeast Michigan