RN Care Manager PACE Bordentown NJ

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range: $40.20 - $53.59

Scheduled Weekly

Hours:

40

This role's function also involves home visits to participants of the LIFE program.

• Assures that participant care is organized, coordinated, and carried out using the Interdisciplinary Team process by competent staff in compliance with established budget; oversees the effective delivery of participant care across the continuum of care.
• Collaborates with Primary Care Physicians and Interdisciplinary team on participant care issues.
• Assesses the quality of care regularly through direct observation and supervision; assures that quality metrics perform to the target level.
• Reviews the plans of care for and with participants and evaluates implementation on a regular basis to assure the delivery of safe and appropriate care; intervenes with staff to improve care as indicated.
• Assures that care is documented completely and accurately. Works with staff to evaluate and determine LOC needs and changes.
• Completes and documents information accurately prior to participant transition of care. Works collaboratively with other agencies to discharge participants to appropriate level of care
• Communicates with each discipline involved in care regarding that discipline’s assessment and plan of care through the transition and assures there is a complete, integrated plan of care reflecting transition of care changes
• Assures all needed services and supplies are in place, authorized and appropriately documented.
• Prevents gaps in care, service, supplies or participant well-being through effective communication
• Makes routine face to face contact with contracted facilities and reinforces those visits through appropriate follow up by phone or electronic means. Coordinates quarterly (at minimum) meetings with IDT members and contracted facility members at the facility.
• Perform quarterly reviews of contracted facilities plans of care. Assures they are accurate, current and appropriately integrated into the LIFE Care Plan (and vice versa).
• Assures that participant issues involving contracted facilities are communicated to all appropriate parties, documented and resolved. Participates in resolution of any facility related grievances as requested (along with appropriate LIFE and facility personnel). Appropriately identifies issues that require inclusion of higher levels of authority to ensure a thorough resolution
• Obtains necessary information and resources for resolution of new or acute complex issues identified by the IDT. Supports the IDT to resolve acute complex issues by coordinating and communicating with needed resources. Assures that needs of participant and family/caregivers are addressed and integrated into resolution
• Attends morning meeting for…