Registered Nurse Case Manager

Summary

The Registered Nurse Case Manager (RNCM) of PACE Southeast Michigan (PACE SEMI) utilizes a systematic approach to nursing practice that encompasses all aspects of the nursing process – assessment, planning, implementation, and evaluation – for frail elders with complex needs. The RN demonstrates a direct relationship between nursing interventions and participant outcomes, leads or directs licensed and non‑professional nursing staff, and focuses on enhancing functional capacity, encouraging autonomy, and coordinating all nursing care.

• Assess participants’ needs and plan appropriate nursing care during initial intake and routine re‑evaluation assessments.
• Collaborate with participants, families, and the multidisciplinary team to develop and revise care plans.
• Maximize participants’ functional capacity by encouraging autonomy in all aspects of care.
• Teach, supervise, and counsel participants and caregivers regarding nursing care needs and related problems using adult learning principles.
• Initiate preventative and rehabilitative procedures or programs as appropriate.
• Administer medications and treatments as ordered, monitor response, and notify medical personnel of status changes.
• Instruct participants/families on safe medication administration and encourage compliance with medication regimens.
• Recognize significance of abnormal test results and apply critical‑thinking skills in data gathering, planning, and implementation.
• Provide safe total patient care to participants with complex health problems, focusing on individual needs and family involvement.
• Maintain nursing practice standards and follow hospital policies and procedures for care delivery and medication administration.
• Lead and monitor licensed and non‑professional staff in nursing care delivery at participants’ homes.
• Provide monthly supervision and documentation of home‑health aide services given in participants’ homes.
• Evaluate participant outcomes and progress toward care‑plan goals; communicate results with the interdisciplinary team.
• Collaborate with the interdisciplinary team to revise care plans based on changes in participants’ physical or psychosocial status.
• Evaluate and document responses to nursing care and teaching interventions during scheduled reviews.
• Maintain accurate records of participants’ functional/health status, progress, plan revisions, and care provided per CSI policies.
• Participate in data collection and documentation for PACE information.
• Advocate for participants and resolve concerns, promoting accountability and the Participant Bill of Rights.
• Provide after‑hours on‑call medical assistance on a rotating basis (phone triage or home visits) as needed; schedule requires rotating on‑call shift.

• Registered Nurse with current Michigan licensure; BSN preferred.
• Participate in annual mandatory in‑service training and screening (infection control, TB testing, safety training, BLS training, etc.).
• Self‑develop through continuing education; serve as role model.
• Current State of Michigan driver’s license with acceptable driving record.
• Establish and maintain interpersonal and interdepartmental relationships.
• Apply adult learning principles in planning and implementing educational activities.
• Lead and direct licensed and non‑professional nursing staff in care delivery.
• Participate in and/or facilitate quality assurance projects and nursing research studies.
• Review current literature relevant to general nursing practice and the PACE model of care.
• Ensure adherence to departmental and external standards, attend professional meetings/committees, and review national standards of practice.
• Meet CMS‑approved competencies before working independently.
• Minimum one year experience with a frail or elderly population.

• Work in participants’ homes (uncontrolled environment); may be exposed to infectious materials, blood‑borne pathogens, and hazardous waste.
• Must be medically cleared for communicable diseases and have up‑to‑date immunizations.
• Driving required within PACE SEMI catchment area, possibly extreme temperatures.
• Reliable transportation must be available daily.
• Tasks involve frequent walking, bending, and lifting 40 pounds or more.