RN Case Manager

St. Paul's PACE Reasner - Bankers Hill, 111 ELM STREET, SAN DIEGO, California, United States of America

San Diego’s St. Paul's PACE program (Program of All-Inclusive Care for the Elderly) serves individuals 55 years or older who are living with chronic illness or disabilities and need coordinated medical care to continue living as independently as possible in their home and community. The healthcare teams l’s PACE provide a hands‑on approach, coordinating medical, social, and home‑care services so that participants no longer need to manage their medical care alone.

This is a Full Time position with a typical schedule of Monday – Friday, 8:00 AM – 4:30 PM.

Job Summary: Under the direction and supervision of the Clinical Services Manager, the RN Case Manager coordinates comprehensive participant care within an interdisciplinary team. The role ensures timely assessments, medication management, care planning, and participant education in accordance with CMS guidelines and organizational standards. The nurse serves as a key clinical liaison between participants, families, PCCs, providers, pharmacies, and home‑care services to promote safe, effective, and continuous care.

Duties and Responsibilities:

• Administer medications in the clinic, including oral, topical, intravenous, vaccinations, and injectable forms, and record all administrations.
• Coordinate comprehensive participant care with the interdisciplinary team; attend IDT meetings and Plans of Care meetings.
• Conduct initial, semi‑annual, annual, and change‑of‑condition assessments in compliance with CMS guidelines; develop comprehensive care plans and travel to participants’ locations as required.
• Maintain participants’ medical records and fulfill CESD charting and reporting requirements; provide quarterly narrative nursing case management notes as needed.
• Determine nursing level of care in accordance with regulations as delegated by the Clinical Services Manager.
• Case‑manage participants on end‑of‑life services to complete initial admission visits.
• Complete in‑home visits for nursing services outside the scope of LVN In‑home Service nurses.
• Develop, update, and maintain accurate nursing care plans that reflect nursing services provided.
• Manage medication‑related processes, including executing new orders, reordering medications, coordinating pre‑ and post‑operative medications, and coordinating pharmacy services and deliveries.
• Communicate updates to Care Kinesis regarding participant contact information changes.
• Maintain and update participants’ Medicare Part A status, including completion and submission of the Part A Notification Form.
• Perform monthly medication verification and reconciliation for participants receiving medication management services.
• Facilitate discharge planning from hospitals or skilled nursing facilities, including management of new prescriptions, ordering DMW, pharmacy coordination, and medication delivery.
• Assist with utilization reduction by reviewing hospital documentation for discharge appropriateness and referring to the End‑of‑Life program when appropriate.
• Collaborate with home‑care team members to coordinate supplies, medications, and in‑home nursing services.
• Attend in‑service education programs, including orientation, skill training, and continuing education.
• Receive in‑service first aid and cardiopulmonary resuscitation training within the first six months of employment.
• Follow all St. Paul’s PACE Policies and Procedures and OSHA safety guidelines.
• Maintain confidentiality of all company procedures, results, and participant information.
• Practice universal precautions and follow infection control procedures.
• Maintain a safe working environment in accordance with St. Paul’s PACE Safety Policies and Procedures.
• Participate in and support quality improvement initiatives.
• Perform other duties as required or requested.

Qualification and Requirements:

• Education – Current California Registered Nurses License; CPR certification required.
• Experience – Minimum of one year working with the frail or elderly population; IV certification preferred. Must have either training or related experience in the assigned job.
• Valid driver’s license and reliable transportation.
• Must be able to clear fingerprints through DOJ and FBI in addition to a drug screen clearance.

Benefits:

• Flexible vacation time – 17 days.
• Paid sick time.
• Education reimbursement – up to $3,000 per year.
• Qualified Public Student Loan Forgiveness (PSLF) employer.
• 403(b) with match.
• Child care available.
• Opportunities for upward mobility.

St. Paul’s Senior Services is an Equal Opportunity Employer.