Care Transition Nurse Manager

Case Management

85%

• Facilitates the exchange of relevant participant information to include but not limited to the participant file of life, facility admission orders, advanced and present directives and care plan between Immanuel Pathways and the contracted facilities to establish continuity of care.
• Communicates with acute care, sub-acute and long-term care facilities regarding status of participants and discharge planning needs. Facilitates communication of related information daily to the Interdisciplinary Team (IDT) in the morning meeting or via email if there is a change in status.
• Participates in Nursing Home rounding and care plan meetings for participants to monitor the status of and communicate with the IDT regarding participant care.
• Collaborates with IDT and attending physician for discharge planning and coordinates participants discharges from facilities to home or to other facilities including transportation, equipment, supplies, arrangements for services and related authorizations.
• Daily hospital rounding to facilitate and assist the IDT in communicating and collaborating with the hospital inpatient care management team.
• Performs a visit to hospitals, SNFs or participants homes within 24 business hours, or the next business day in the event of a weekend or Holiday admission to ensure participant and/or family needs are being met and questions are answered.
• Documents care coordination information in the participants electronic health record (EHR) in a timely manner in accordance with Immanuel Pathways documentation standards.
• Monitors status and services of participants at contracted facilities, to ensure participants are maintained in the most appropriate setting while promoting independence, safety and quality of care.
• Collaborates with Immanuel Pathways Quality Managers on Quality Improvement projects related to transitions of care services and related satisfaction survey outcomes.
• Makes referrals, or collaborates with Social Work to make referrals, to other agencies or services as needed.
• Documents in the EHR progress notes on the relevant and specialized nursing services he/she provides.
• Develops relationships with discharge planners in the network.
• Monitor participants weekly the first 30 days of transitioning from one care setting to the next including, but not limited to the nursing home admission or discharge and hospital discharges, to ensure seamless coordination of services.
• Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants and families.
• Analyzes skilled services, inpatient utilization and clinical data available to ensure appropriateness of medical necessity of services requested and received.
• Identifies and escalates quality of care issues through appropriate channels.
• Collaborates with inpatient medical team and skilled nursing team to secure appropriate options and necessary services.
• Collaborates with Provider Relations Specialist to educate contracted vendors on the PACE philosophy and model of care.

Participant Care

5%

• Provides support to Clinic RNs with all processes as needed.
• Assists in treatment, examination and testing of participants as needed.
• Assures certain health and personal care services are provided.
• Educates participants, family and caregivers in regards to care, medications and treatments as needed.

Compliance

5%

• Acts within the scope of his or her authority to practice.
• Implements Exposure Control Plan.
• Complies with Emergency Preparedness Plan.
• Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants and families.

• Participates in and supports Quality Improvement Initiatives.
• Completes internal or external ISIS PACE Reviewer training.
• Completes Security Review process for system access in the respective state in which he/she is employed.

• Maintains up to date knowledge of system\process and communicates to IDT as applicable.

Other

5%

• Participates in continuing education classes and any required staff and training meetings.
• Maintains professional affiliations and any required certifications.
• Travels between the various Immanuel Pathways Centers as needed.
• Performs other duties as assigned or requested.