Nurse Case Manager (63017)

Nurse Case Manager (63017)# Nurse Case Manager (63017)Learning Center - Springfield, PA 19064## OverviewPosition TypeFull TimeJob ShiftDayEducation Level2 Year DegreeTravel PercentageUp to 50%CategoryHealth Care## DescriptionThe Nurse Case Manager is a Licensed Practical Nurse (LPN) or Registered Nurse (RN) who provides direct clinical care, care coordination, and case management for approximately 15-20 individuals with medical fragility, Intellectual and Developmental Disabilities (IDD), and Mental Health (MH) diagnoses living in Pennsylvania group homes regulated under 6400 standards. The role combines hands-on nursing care with case management to ensure services are timely, person-centered, cost-effective, and aligned with individual needs. Responsibilities include clinical care such as obtaining weights and blood pressure, wound assessment, and catheter care; coordinating appointments and services; managing medication and equipment needs; supporting care transitions; and training direct support professionals (DSPs) to recognize emergencies and provide daily care that promotes positive health outcomes.**DUTIES AND RESPONSIBILITIES:*** Perform clinical tasks including, but not limited to, wound care, feeding pump support, fall-risk assessment, lung and abdominal exams, post-ER and post-hospitalization assessments, and troubleshooting catheters, feeding pumps, and adaptive durable medical equipment.* Conduct comprehensive nursing assessments to identify medical, functional, behavioral, psychosocial, and support needs, along with related risks and barriers.* Develop, implement, and update individualized care plans and nursing recommendations based on physician orders, assessments, individual goals, and changing needs.* Train and coach staff on personal care, repositioning, vital signs, emergency recognition, and response to urgent medical situations, including 911 emergencies.* Coordinate care with contracted nurses, physicians, specialists, therapists, hospital staff, and community providers to ensure continuity of care.* Monitor health status and treatment response, follow up on recommendations, and adjust care coordination priorities to support safe transitions and positive outcomes.* Obtain needed education and train staff on the proper use of prescribed adaptive equipment, nutrition plans, and required meal textures.* Serve as the primary contact for physicians and specialists by preparing appointment paperwork and supplying relevant test results, referrals, authorizations, and treatment information.* Maintain accurate, timely, and confidential documentation in the electronic health record, including medical history, case notes, assessments, appointments, and care coordination activity.* Order new medications and refills through the pharmacy system, communicate medication changes, and confirm medications are received by the homes.* Support and review medication administration record (MAR) documentation, observe medication administration, and provide feedback to ensure compliance and accuracy.* Audit medications to ensure correct texture, preparation, and administration method.* Educate individuals, families, medical decision makers, next of kin, and staff on diagnoses, treatment plans, medications, equipment, and available resources.* Coordinate care during ER visits, hospitalizations, and discharges, communicate with hospital staff, update records with new orders, and ensure follow-up recommendations are implemented.* Advocate for access to healthcare services, benefits, equipment, and community-based supports.* Participate in team meetings, case conferences, quality improvement activities, and medical appointments as required.* Keep electronic and paper charts current to support staff access to accurate information and promote health and safety.* Completes HRST Clinical Reviews of those in their caseload and communicates changes to the team.* Participate in rotating on-call duties as assigned.* Perform other duties as assigned.## Qualifications**Education/Experience/Skills Requirements*** Active Pennsylvania licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN).* Experience in Community Living Arrangements, care coordination, and case management.* Three (3) years of experience supporting individuals with multiple disabilities, including knowledge of safety and communication needs for individuals with physical disabilities.* Strong clinical judgment and the ability to solve problems and make decisions independently.* Experience with feeding tubes, colostomies, tracheotomies, catheter care, and wound care strongly preferred.* Knowledge of healthcare regulations, payer requirements, community resources, and documentation standards relevant to the role.* Ability to manage multiple priorities in a fast-paced environment with strong attention to detail, organization, and time management.* Ability to work effectively on an interdisciplinary team and communicate clearly in writing and verbally.* Ability to anticipate changes, identify issues, and take appropriate action.* Intermediate proficiency in Microsoft Word, Excel, Outlook, SharePoint, and PowerPoint.* Experience using electronic management systems and electronic health records.* Ability to perform CPR, First Aid, and crisis intervention using agency-trained protocols.* Ability to attend off-site meetings as needed.* Ability to work nights and weekends as needed. #J-18808-Ljbffr Swarthmore, PA