RN Care Manager

Role Scope: 

In this role, you will be responsible for the management and delivery of direct nursing care to our participants in a variety of settings including, but not limited to, the clinic, adult day center, participant’s home, virtually, and SNF.  You will serve as a critical member of the Interdisciplinary Team (IDT) and work collaboratively to complete assessments and drive forward participant care plans as “quarterback” for your panel.  

Core Responsibilities & Expectations for the Role 

• Contribute to a center experience that Participants want to spend time in, a team culture that cares and creates joy, and an environment where all participants and team members belong. 

• Continue to raise the bar.  Constructively seek and share feedback and help us implement changes in order to improve clinical outcomes and experience for participants. 

• Exhibit and honor Habitat’s Values. 

• Participate and facilitate  in Interdisciplinary Team (IDT) meetings by contributing insights from assessments, care plan recommendations, and care coordination in a collaborative spirit. 

• Conducts face-to-face nursing assessments that are inclusive of physical, psychosocial, and behavioral statuses in various settings, primarily in the Habitat center but also in–home. 

• In partnership with a medical provider, delivers personalized care for a panel of participants based on care plans. 

• Delivers and documents nursing interventions as agreed upon in participant's care plans, promptly and accurately responding to physician orders, and correctly administering medications and therapeutic interventions. 

• Provides case management longitudinally and during transitions of care. Proactively coordinates complex patient discharges, transfers, and immediate post-discharge needs with hospital and long-term care facility case managers  

• Coordinates all aspects of care delivery including medication management, medical equipment and supplies, and specialist and diagnostic referrals  

• Triages in the outpatient setting, which includes independently initiating therapies within scope of practice and collaboratively working with a medical provider to escalate care as needed. 

• Educates participants, caregivers including family members, and team members on how to personalize and carry out care plans. 

• Aid with all wound care (including complex wounds), IV (hydration, therapies), and any additional procedures within RN scope of practice identified to meet evolving participant needs. 

• Delegates tasks to MA and Licensed Vocational Nurses within their respective scopes of practice. 

• Remotely takes after-hour calls that are triaged on a rotating schedule. 

• Performs related duties as assigned. 

Required Qualifications:  

• Graduate of an accredited school of nursing; Bachelor of Science (BSN) preferred. 

• Unencumbered Registered Nurse (RN) license required. 

• Minimum 2-4 years of experience clinically caring for medically complex or older adults’ population as an RN.   

• Minimum 1-2 year's experience in case management.  

• Strong clinical acumen in chronic disease management and complex geriatric care. 

• Demonstrates experience in management of clinical interventions: wound care, IVs, phlebotomy, colostomy/ileostomy care, etc. 

• Proof of medical clearance for communicable diseases, including a TB test. 

• Proof of all immunizations are up to date. 

• Proof of current CPR/BLS certification required or requirement to obtain within 30 days of employment.goaidata