Lead RN Case Manager Detroit
Company: PACE Southeast Michigan
Posted on: May 28, 2023
LEAD RN CASE MANAGER
The Registered Nurse Case Manager (RNCM) of the 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 RN 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
RN 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.
SPECIFIC DUTIES AND FUNCTIONS:
- The RNCM assesses participants' needs and plans for appropriate
nursing care upon the Initial Intake Assessment as well as upon
routine Re-Evaluation Assessments.
- The RNCM works and collaborates with the participant and the
family, as well as all members of the multidisciplinary Team in
developing the participant's plan of care.
- The RNCM maximizes the participant's functional capacity by
encouraging autonomy in all aspects of care.
- The RNCM teaches, supervises and counsels the participant, or
caregiver regarding nursing care needs and other related problems.
The RN utilizes adult learning principles when planning for and
implementing educational information to the participants,
caregivers or family members.
- The RNCM initiates preventative and rehabilitative procedures
or programs as appropriate for the participants' care and
- The RNCM administers medications and treatments, as ordered by
the physician/NP, and monitors the participant's response. The RN
notifies the appropriate medical personnel of changes in the
- The RNCM demonstrates knowledge of the medications he/she
administers and instructs the participant/family in safe
administration of medication in the home. Assesses for and
encourages compliance with medication regimen.
- The RNCM recognizes and understands the significance of
abnormal test results and utilizes critical thinking skills when
gathering participant data, planning for, and implementing
- The RNCM provides safe total patient care to participants with
complex health problems with a focus on the individual participant
and the family.
- The RNCM maintains all standards of nursing practice and
follows hospital policies/procedures for care delivery and
- The RNCM leads and monitors licensed and other professional and
non-professional staff in the delivery of nursing care to the
participant in the home. The RN is responsible for monthly
supervision and subsequent documentation of home health aide
services provided in the participant's home.
- The RNCM evaluates participant outcomes and or progress toward
achieving the objectives/goals of the care plan and communicates
this information among other members of the Multidisciplinary
- The RNCM collaborates with the Interdisciplinary Team to revise
the plan of care based on changes in the participants' physical or
psychosocial status, and initiates actions that are consistent with
the changes in status.
- The RNCM participates with patients, families and members of
the Interdisciplinary Team to evaluate/measure the individual and
group response to nursing care and teaching interventions and
documents the outcomes of the problems identified at every
- The RNCM maintains accurate and timely records of participant's
functional /health status, progress toward care plan outcomes,
revisions to care plans, care given, etc. All charting and
documentation is performed in accordance with CSI
policies/procedures. The RNCM participates in the collection and
documentation of Data PACE information.
- The RNCM advocates to others on behalf of the participant, and
demonstrates accountability in resolving participant concerns or
- The RNCM understands, complies with and promotes the
Participant Bill of Rights and assesses and works toward achieving
high levels of participant satisfaction.
- The RNCM may provide after hours on-call medical assistance on
a rotating basis, via phone triage or after hours home visits to
participants as needed.
- Schedule requires a rotating on call shift. KNOWLEDGE, SKILLS
- Must be a Registered Nurse with current Michigan licensure, BSN
- The RNCM participates in annual, mandatory in-service training
and screening, including but not limited to: infection control, TB
testing, safety training, and BLS training.
- The RNCM assumes responsibility for self-development through
continuing education, utilizing resources within the health care
system or elsewhere; the RN promotes professional behavior and
growth by serving as a role model within the health team.
- The RNCM must possess a current State of Michigan driver's
license and maintain an acceptable driving record.
- The RNCM has the ability to establish and maintain
interpersonal and interdepartmental relationships.
- The RNCM has the ability to apply principles of adult learning
in planning and implementing educational activities.
- The RNCM has the ability to lead and direct other licensed and
non-professional nursing staff in the delivery of care.
- The RNCM participates in and/or facilitates Quality Assurance
projects resulting from data results.
- The RNCM assists with the implementation of nursing research
- The RNCM reviews current periodical literature relevant to the
general practice of nursing as well as information pertaining to
the PACE model of care.
- The RNCM ensures adherence to departmental and external
standards in the provision of quality focused care by attendance at
professional meetings/committees and review of national standards
- Must meet a standardized set of competencies (approved by CMS)
before working independently.
- Must have one (1) year of experience with a frail or elderly
population. WORKING CONDITIONS:
- Works in the participant's home which is an uncontrolled
- 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 before engaging in direct participant
- Driving is required within PACE SEMI catchment area, with
possible exposure to extreme temperatures, including heat and cold.
Must have reliable transportation available on a daily basis.
- Frequent walking, bending, lifting of forty (40) pounds or more
may be needed in the performance of duties.
Keywords: PACE Southeast Michigan, Detroit , Lead RN Case Manager Detroit, Executive , Detroit, Michigan
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