Complex Nurse Case Manager - 240678 New

About this Role

This is an opportunity for a mission-driven team player who is passionate about delivering high quality, integrated care to frail older adults. In this role, you will be responsible for the management and delivery of direct nursing care to PACE (Program of All-inclusive Care for the Elderly) participants in a variety of settings including, but not limited to, the clinic, adult day center, home, virtually, SNF and beyond. You will serve as a critical member of the Interdisciplinary Team (IDT) and work collaboratively to complete assessments and drive forward participant care plans. This is a chance to join a new culture of care delivery that prioritizes quality, outcomes, teamwork, and empathy in how we personalize our model to focus on what matters most to each participant. This role will allow you to practice at the top of your license, promoting ongoing learning and development of professional expertise.

Expectations for the Role

• The Complex Care RN is primarily focused on providing clinical care onsite in the clinic, with some responsibilities in case management. This role supports participants directly by addressing their clinical needs, managing care coordination, and ensuring overall patient well-being within the facility.
• Participates in Interdisciplinary Team (IDT) by contributing insights from assessments, care plan recommendations, and care coordination in a collaborative spirit.
• Conducts face-to-face nursing assessments that are inclusive of physical, psychosocial, and behavioral statuses in various settings (home, day center, virtual, long term care facility, etc.)
• In partnership with a medical provider, delivers personalized care for a panel of participants based on care plans.
• Delivers and documents nursing interventions as agreed upon in participant’s care plans, promptly and accurately responding to physician orders, and correctly administering medications and therapeutic interventions.
• Triages in the outpatient setting, which includes independently initiating therapies within scope of practice and collaboratively working with a medical provider to escalate care as needed.
• Provides case management during transitions of care and proactively communicates with hospital and long-term care facility case managers for care coordination.
• Educates participants, caregivers including family members, and team members on how to personalize and carry out care plans.
• Remotely takes after hour calls that are triaged by a nurse team on a rotating schedule.

Attributes of an Ideal Candidate

• Passion and mission orientation for serving high-risk seniors and frail older adults.
• Minimum 2 years of experience clinically caring for medically complex or older adult populations preferred.
• Active listening and conflict management skills
• Adapts quickly to multiple clinical settings.
• Strong clinical acumen in providing clinical interventions to complex participants.
• Demonstrated experience in wound care, IVs, phlebotomy, colostomy/ileostomy care, etc.
• Active, unrestricted RN license in California
• Graduate of an accredited School of nursing, BSN strongly preferred.