The Registered Nurse Case Manager performs daily coordination of acute and post-acute care with facility staffing. The RN Case Manager actively assists providers and facility staff in managing InnovAge admitted participants by facilitating care through interaction with facility departments and community services. Reviews for medical necessity and level of care appropriateness in collaboration with the InnovAge IDT while coordinating post-facility discharge planning and support utilization review and improvement activities. The role aims to optimize positive health outcomes and prevent hospital readmissions by focusing on the transitional care period.
Participant Nursing Care Coordination – 70%
- Assesses, develops, plans, and evaluates care provided to participants while admitted to hospital settings via facility EMR and discussions with facility staff.
- Collaborates with providers, other members of the interdisciplinary health care team, and patient/family in the development, implementation, and documentation of appropriate, individualized plans of care to ensure continuity, quality, and appropriate resources upon discharge.
- Participates in the daily IDT meeting and formulating Plans of Care for InnovAge PACE program participants, as well as in other interdisciplinary team settings that plan, coordinate, and monitor the care of InnovAge PACE program participants.
- Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.
- Collaborates with facility staff to develop and coordinate the implementation of a discharge plan to meet participants’ identified needs.
- For participants discharging to home, coordinates with IDT to identify new equipment and/or service needs.
- Communicates the plan to providers, patients, family/caregivers, staff, and appropriate community agencies.
- Ensures scheduling of appointments for post-discharge care for primary care and/or home care visits and ensures priorities are made based on participants’ needs.
- When appropriate, provides participants with verbal education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
- Documents all necessary information and maintains participant medical record(s), and fulfills agency charting and reporting requirements.
- Complies with all regulatory and policy, and procedure guidelines.
Utilization Management – 30%
- Maintains an ongoing list of participants who are currently hospitalized and obtains daily updates regarding their condition and discharge plans. Relays these updates to IDT daily.
- Maintains an ongoing list of participants receiving skilled services in a SNF. Relays updates to IDT as appropriate.
- Sends any clinical updates, therapy evaluations, discharge summaries, etc., received from hospitals to IDT for review.
- Participates in IDT discussions of ongoing SNF stays, aware of reasons for long stays and barriers to discharge.
- Closely monitors all patients at skilled status within SNFs, including short-stay and long-stay residents, working with the IDT to ensure that skilled status is only provided when necessary and for the minimum number of needed days.
- Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation.
- Maintains and reviews participant records, charts, and other pertinent information.
- Requests documents of hospital stay and diagnostic results for participant records when needed.
- Effectively communicates in interdisciplinary team meetings, family meetings, and clinic meetings.
- Identifies relevant staff involved in discharge planning at frequently used hospitals and maintains ongoing relationships with these staff members.
- Visits the PACE center, hospitals, and contracted SNFs quarterly to build relationships
REQUIRED
- Associate degree in nursing
- Current State-issued Registered Nurses License
PREFERRED
- 3 years coordinating care and discharge planning
- 3 years health care experience with emphasis in geriatrics
- Bachelor’s degree in nursing
- Bi-lingual
- Certification as a Gerontological Nurse
InnovAge is dedicated to empowering seniors to live independently, allowing them to age in their own homes and communities safely. InnovAge offers an alternative to nursing homes through its Program of All-inclusive Care for the Elderly (PACE), which provides enrolled seniors with customized healthcare and social support at PACE Adult Day Health Centers. These centers are staffed by medical professionals who are committed to creating personalized care plans for each participant. At InnovAge, our team members are our greatest asset and have a significant impact on the lives of our participants every day. When you join InnovAge, you'll work alongside talented, respectful, and passionate colleagues within a patient-centered care model.
InnovAge is committed to equal opportunity and affirmative action, and we strive to create a diverse and inclusive workplace. We consider all qualified candidates for employment without discrimination based on race, color, religion, sex, sexual orientation, gender identity/expression, national origin, disability, protected veteran status, pregnancy, or any other protected status. Salaries are determined by various factors such as qualifications, experience, and location, and do not include potential bonuses or benefits. Our extensive benefits package includes medical/dental/vision insurance, short and long-term disability, life insurance and AD&D, supplemental life insurance, flexible spending accounts, 401(k) savings, paid time off, and company-paid holidays.
Applicants are considered until the position is filled.
Salary Range MinimumUSD $102,000.00/Yr.
Salary Range MaximumUSD $112,900.00/Yr.
