RN Case Manager, Jordan Valley Senior Care (JVSC) PACE

Overview

The RN Case Manager is a core member of the PACE Interdisciplinary Team (IDT), responsible for the ongoing clinical management of an assigned participant caseload/panel. This role coordinates and delivers care across home, clinic, and facility settings, manages comprehensive assessments, and leads the development and execution of individualized care plans. The RN Case Manager serves as the primary clinical point of contact for a defined panel of participants, ensuring continuity of care, chronic condition management, and timely response to changes in participant status, in accordance with PACE regulatory and quality standards.

Key

Responsibilities

Caseload & Panel Management

Manage a defined caseload/panel of participants, serving as their primary nursing point of contact across the care continuum. Maintain ongoing clinical accountability for panel participants, including tracking status changes, care needs, supplies, medications, and follow-up items across care settings. Prioritize and triage panel workload based on acuity, urgency, and scheduled care requirements.

Participant Visits

Conduct a regular mix of home visits, clinic-based visits, and facility visits (e.g., skilled nursing, assisted living, hospital) to assess and manage participant care. Adjust visit frequency and setting based on participant acuity, care plan requirements, direction from/collaboration with PCP and clinical judgment. Coordinate visit scheduling with the transportation, home care, and IDT teams to ensure timely access to care.

Assessments & Care Planning

Complete comprehensive initial, semi-annual, and status change assessments in accordance with PACE and CMS/state requirements. Develop, implement, and update individualized care plans in collaboration with the participant, caregivers, and IDT. Identify and document changes in condition, functional status, and risk factors; initiate care plan revisions as needed. Ensure assessments and care plans are completed within required regulatory timeframes and accurately documented in the EMR.

Chronic Care Management

Monitor and manage participants with chronic conditions (e.g., diabetes, CHF, COPD, dementia) to prevent avoidable decline, ER visits, and hospitalizations. Provide participant and caregiver education on disease management, medication adherence, and self-management strategies. Coordinate chronic care needs with primary care providers, specialists, and ancillary services.

Interdisciplinary Team Collaboration

Actively participate in IDT meetings, presenting panel updates, assessment findings, and care plan changes. Communicate and collaborate with physicians, social workers, therapists, dietitians, and other IDT members to ensure coordinated, person-centered care. Serve as a clinical liaison between participants/caregivers and the IDT.

Care Coordination & Transitions

Coordinate care transitions across settings (hospital, skilled nursing facility, home) to ensure continuity and safety. Follow up on hospital and facility discharges to confirm timely implementation of updated care plans. Coordinate referrals to specialists, ancillary services, and community resources as needed. Participate in an on-call rotation with other clinical and administrative staff, including potential for phone calls and home/facility visits.

Documentation & Compliance

Maintain accurate, timely, and complete clinical documentation in the electronic medical record. Ensure compliance with all applicable federal, state, and PACE program regulations, as well as organizational policies. Support quality improvement initiatives and participate in audits, chart reviews, and regulatory surveys as needed. Promote the education and development of students, interns, residents, apprentices, and other new staff by sharing expertise, responding to questions, and fostering a positive and supportive learning environment. Perform other duties as assigned by JVSC leadership.

Benefits

Overview

Medical and Prescription Drug Coverage: Three comprehensive plan options (Buy-up, Base, and High Deductible) through UnitedHealthcare's Choice Plus network, covering various deductibles and out-of-pocket limits. Includes access to telemedicine services via Teladoc. Health Savings Account (HSA): Available for employees in the High Deductible Plan with employer contributions and tax advantages.

Flexible Spending Account (FSA): Options for both healthcare and dependent care FSAs, allowing pre-tax contributions for qualified expenses. Dental and Vision Coverage: Dental insurance through Cigna’s DPPO network and vision coverage through EyeMed’s Insight network. Retirement Plan: Pre-tax and Roth 403(b) retirement plans with a 5% employer match starting after 30 days of employment.

Life and Disability Insurance: Basic Life and AD&D insurance provided at no cost, with the option to purchase additional coverage. Long-term and short-term disability insurance are also available. Employee Assistance Program (EAP): Free confidential support for personal and professional challenges, including counseling and crisis intervention.

Additional Voluntary

Benefits

Options for critical illness, accident, hospital care, and pet insurance through MetLife. Pay on Demand Available.

Holidays

Nine paid holidays per year.

Health

Requirements

All employees are required to provide proof of vaccination for Flu, Hepatitis B and Tuberculosis (TB) as part of our commitment to maintaining a safe and healthy workplace.

Qualifications

Graduate of an accredited school of nursing (Associate's or Bachelor's degree in Nursing required) Current, unrestricted RN Licensure in state of practice in good standing, received from a qualified, accredited school of nursing Current BLS Certification required within 90 days of hire. Either one year of experience working with a frail or elderly population or, in the absence of such experience, receive appropriate training from the JVSC on working with a frail or elderly population upon hire. Valid driver's license and reliable transportation required for home and facility visits. Minimum of 2 years of clinical nursing experience required

Preferred

Qualifications

Bachelor of Science in Nursing (BSN) preferred Geriatric, home health, case management, or community-based care experience strongly preferred. Prior experience with frail or elderly populations, chronic disease management, or interdisciplinary care models preferred. PACE program experience a plus.