Job Description
Certification Details
- BLS
- California State Nursing License
Job Details
- The Case Manager is a member of the Interdisciplinary Care Team WelbeHealth (ICT) and collaborates to deliver and manage all aspects of participant care.
- Conducts required PACE assessments and develops individualized participant Care Plans.
- Addresses patient needs, communicates with participants and families, advocates for participant needs.
- Delivers care in center, participant’s homes, skilled nursing facilities, or other care settings.
- Manages participant and family care needs in partnership with the Primary Care Provider.
- Takes ownership of outcomes and quality of care for assigned participant panel.
- Conducts in-clinic, at home, and virtual PACE required assessments (minimally every 6 months).
- Educates participants and support network on acute, chronic, and end-stage conditions.
- Performs urgent and routine virtual or in-person follow-up visits as determined by participant’s risk stratification and needs.
- Develops and implements discipline specific plan of care in collaboration with IDT, participants, families or POAs.
- Identifies participant problems and needs, prioritizes and escalates to Primary Care Provider as appropriate.
- Coordinates care for participants with highest complexity including hospital, ER, and skilled facility levels with Complex Care Team.
- Attends to Clinical Inbox in collaboration with PCP to ensure timely completion of orders, review of test results, and appropriate follow-up.
- Performs and documents ordered procedures and care in clinic or home visits as directed by PCP.
- Communicates participant changes to interdisciplinary team including post-procedure or post-discharge needs.
- Coordinates with Complex Care Team on participant discharges and transitions of care including hospice transitions.
- Reviews medical test results and works with provider on timely responses and documentation.
Job Requirements
- Minimum of two years’ nursing experience in a clinical setting with frail or elderly population.
- Nursing knowledge and skills necessary to treat frail, elderly participants and manage complex clinical situations.
- Highly motivated, self-directed, able to execute tasks in a quickly changing environment and make sound decisions in emergency situations.
- Excellent clinical, organizational and communication skills with seniors, families, and interdisciplinary team members.
- Ability to multi-task and contribute toward projects, timelines, and process improvement initiatives.
- Ability to work independently with minimal supervision.
- Demonstrated ability to prioritize in a fast-paced environment.
- Experience and competency working with people from diverse backgrounds and cultures.
- Commitment to unlocking the full potential of vulnerable seniors.
Additional Details
- Bilingual English/Spanish preferred.
Job Tags
Immediate start, Remote job,