Hybrid Nurse Case Manager - FT bei EverTrue

Job Description: 

Introduction:

At EverTrue, team members at all levels find their calling in our mission of Older Adults Living Life to the Fullest. In this work environment, all team members are part of a community and appreciated by the people they work with – residents and coworkers – every day. 

Summary:

Responsible for assisting in coordinating the necessary services of care that a PACE participant needs to maintain their highest level of functioning.

Essential Duties and Responsibilities:

Prioritizes the needs and preferences of participants

Ensures participants are actively involved in the decision-making regarding their care journey

Communicates key information amongst IDT members including:

On-call concerns Service requests Follow-up on outstanding concerns Changes in condition Prior day clinic concerns Same-day clinic visits

Reports and follows care of participants in the Assisted Living, Skilled Nursing, and/or Hospital setting:

Status Updates Notable concerns Anticipated discharge date beginning day 1 Identified gap between services being provided in current setting vs. more independent setting.

Completes the reconciliation of medications, and addresses any discrepancies or issues in a prompt manner

Ensures participants’ appointments are scheduled according to the PACE program standards, protocols, and regulations

Establishes appropriate communication with physician, nursing, therapy provider and/or social worker as needed for the participant

May complete initial assessment of participant to ascertain care needs including physical, emotional, and mental status

Coordinates medication management, sets up meds weekly, communicates with family and physician as necessary

Educates physicians, social workers, discharge planners, and community at large about services that EverTrue PACE provides

Follows up on requests for services, equipment, and other necessary items that participant needs

Serves as an educational resource to staff members and the community

Acts as a resource to residents and family members regarding services provided by PACE

Remains available in the clinic on a scheduled basis as needed for participants

Looks for opportunities to interact/build relationships with participants

May facilitate referrals to PACE network healthcare providers

Completes assessments and home visits for participants as needed, identifies potential problems, and suggests possible solutions

Develops and updates the plan of care for participants

Knowledge, Skills, & Abilities:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.

-Graduate of an accredited School of Nursing

-Current Missouri RN or LPN License in good standing

-Must be CPR BLS (basic life support) certified with the American Red Cross

-A minimum of two years nursing experience preferred

-Good communication skills

Physical Requirements and Working Conditions:

The physical activities and demands described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.

While performing the duties of this job, the employee is regularly required to stand; walk; use hands to finger, handle, or feel objects, tools, or controls; and talk to hear. The employee frequently is required to sit; reach with hands and arms; and stoop, kneel, crouch, or crawl. The employee is occasionally required to climb or balance and taste or smell. The working conditions include: • A well-lit and ventilated working area. • Appropriate ergonomic and personal safety equipment is provided if needed. • Minimal exposure to chemicals and hazardous waste. • Noise level in work environment is usually quiet. • Travels out in the community that allows for exposure to weather conditions and potential for unsafe environments.

This job description in no way states or implies that these are the only duties to be performed by the employee occupying this position. Employees may be required to follow other job-related instructions and to perform other job-related duties as requested, subject to all applicable federal, state, and local laws and standards. Certain job functions described herein may be subject to possible modification in accordance with applicable federal, state, and local laws and standards.

Additional Information:

N/A