Works under the general supervision of the Clinic Manager and oversight by the PACE Physicians, the Nurse Case Manager/Care Coordinator has the responsibility to case manage all PACE participants who are in the ambulatory/home setting for the assessment of health needs and contributing to the plan of care, initial implementation of nursing care plans and providing nursing care, as well as periodic re-evaluation of individual and family nursing needs. 

Responsibilities
•       Provides technical, organizational, and interpersonal skills necessary to coordinate the scheduling, communication, and billing documentation of all aspects of the plan efficiently and effectively for home care. 
•       Ensures continuity of home care service delivery and compliance with all governing regulations and agency policies and procedures. Assesses, using the nursing process, the home and care needs of a frail elderly population, and identifies and develops specific plans of care.
•       Ensures physician plan of care is executed and that all tests, procedures, consults, and other necessary diagnostics are completed in a timely manner. Communicates barriers to completing physician plan of care to the PACE Primary Care Provider or the Clinic Manager.
•       Actively participates in Interdisciplinary Team Meetings, assuring needed documentation and assessments are complete prior to the meetings.
•       Gives skilled nursing care and prescribed treatments to participants in their homes or at the adult day health center and demonstrates nursing care to participants and families.
•       Communicates effectively with hospital departments to minimize hospital lengths of stay as appropriate and allow for a smooth transition for the client as he/she moves from the hospital to alternative levels of care.
•       Conducts a nursing admission assessment to facilitate the admission and care plan process.
•       Provides functional supervision to caregiver staff and directs the provision of quality paraprofessional care.

•       Assists in design of systems for training, orienting, in-servicing, and supervising in-home caregiver staff according to program needs and regulatory requirements.

•       Compiles and uses records, reports and statistical information for evaluation and planning of the assigned programs.

•       Coordinates staff roster and schedules for all home care on a daily, weekly and monthly basis to create the most time efficient and cost effective schedule to meet the needs of participants.

•       Participates in Committees as requested by the Director of Clinical Operations or the Clinic Manager. May chair committees and task forces.

•       Knows and adheres to the philosophy and goals of High Desert PACE.

•       Participates in quality management program activities, including peer reviews.

•       Effectively communicates with clients and their families regarding home care needs, concerns and/or problems with coverage.

•       Advises the Clinic Manager in ways and means to establish better accountability of High Desert PACE services to participants and referral sources.

•       Is professional in appearance and manner in the clinical area; recognizes own limits and seeks help and guidance from the Director of Clinical Services as appropriate; responds in a positive manner to constructive criticism; serves as a role model for students and staff members.

•       Attends required staff meetings/trainings and voluntary professional development courses

Performs related duties as assigned; including providing temporary coverage for other sites as needed and assigned by your supervisor. 

Education and Training
·     Degree/diploma in nursing.
·     RN with current license to practice as a professional nurse in the state of California
·       Bachelor of Science in Nursing, preferred.
·       Minimum of total of one year of personal, clinical/leadership, and/or employment experience providing care or services for a frail or elderly population required.
·       Experience in a home health agency, community-based or long-term care setting involving the elderly preferred.
·       Two years of community nursing preferred.
·       Proficient in computer operations acquired either through work experience or education, including word processing and spreadsheet programs.
·       Ability to understand and prepare moderately complex written materials.
·       Excellent verbal and written communication skills.
·       Ability to work without close supervision and to exercise independent judgment.
 ·Ability to organize multiple tasks and projects and maintain control of workflow.
Skills and Abilities
·     Knowledge of physical, mental and social needs of frail older adults.

·     Effective skills in physical assessment and chronic disease management for frail older adults.

·     Effective listening and oral and written communication skills.

·     Demonstrated ability to work effectively within the interdisciplinary team setting.

·     Computer proficiency.

·     Able to manage changing priorities per participant needs.

·     Strong organizational skills.

·   Demonstrates necessary skills and knowledge as outlined in the position-specific Competency Assessment Profile.
Working Conditions
The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
·        Must be able to work required schedule.

·        Requires physical strength to perform essential functions of the job.

·        Occasional travel between sites, nursing/group homes and to members’ homes required.

·        Requires use of personal vehicle.

·        Requires valid driver’s license.

·        Requires proof of automobile insurance coverage at the following minimum amounts in order to be reimbursed for mileage.

·        May require use of personal cell phone for business purposes (may be eligible for stipend)