Nurse, (RN) CM/CC Team Leader M - F 7:30 am - 4:30 pm
Posted on: May 3, 2021
Under general supervision by the Supervisor, Nursing and
oversight by the PACE Physicians, the Nurse (RN) Case Manager/Care
Coordination Team Leaderhas the responsibility to case manage all
PACE participants who are in the ambulatory setting.
Develop the nursing component in the plan of care for patients,
specifying short- term nursing goals in each individualized plan of
care. Responsible for Initial Assessment for potential new
enrollees (Home-Visits to support environmental and physical
assessments). Responsible for ensuring coordination and completion
of reassessments every 6 months 1:1 at Center and/or Home for
assigned case load. Responsible for the allocating in home
supportive caregiver hours based on the Nurse and the IDT
Assessment. Activities of Daily Living and Instrumental Activities
of Activities Living (ADL's and IADL's). Acts as a liaison between
the Participants and the Interdisciplinary Team Members. Acts as a
liaison between homecare services and PACE center services to
ensure adequate coordination and effectiveness of program delivery.
Provides P/P/C, Family, and Caregiver Individual Health Education
on Disease Process. Elements of the health education process
include verbal and written hand-outs for their reference. Documents
any activities encountered between the participant, families,
caregivers, contracted providers, hospitals, SNF, and other
facilities working together with PACE for participant's well being.
Troubleshoots issues with RN Supervisor and providers. Responds to
medical emergencies and will take the lead in management of the
situation as indicated. Functions as Patient Advocate, ensuring
that patient concerns are resolved or addressed expeditiously.
Screen and triage "walk-in" and "call-in" patients as needed.
Ensures the implementation and compliance of patient care as per
provider's order. Collaborates and Supports and reports
infection-control policies and procedures as necessary for PACE.
Document all nursing care on the day the service is rendered while
adherening to PACE documentation guidelines and all PACE policies
and procedures related to medical care provision. Monitor,
administer, and record ordered medications. Participates as an
active member of the INTER-disciplinary team (IDT) to assess the
nursing need of the patient. Collaborates and coordinates to ensure
efficient operations in PACE, or clinical setting, i.e. staffing.
Maintains acceptable standards of nursing care, based on regulatory
requirements, as well as JCAHO and AltaMed standards. Assists with
preparing for various quality, county, state, and federal audits.
Assumes the role of Supervisor, Nursing in his/her absence and
assists in completing subordinate's performance evaluations as/if
needed. Performs other related duties as assigned.
Current valid License as a Registered Nurse through the
California Board of Registered Nursing. A minimum of one year
experience in Geriatric Nursing required. A minimum of one year
experience preferred in managed care setting, preferably in
utilization or case management in ambulatory or inpatient setting.
CPR/First Aid Certificate required. Bilingual English and Spanish
Keywords: AltaMed, Covina , Nurse, (RN) CM/CC Team Leader M - F 7:30 am - 4:30 pm, Other , Covina, California
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