RN Case Manager (RN #)
Company: Total Community Options, Inc. dba Innovage
Posted on: March 27, 2020
Job Summary Under the direction and supervision of the Clinic
Nurse Manager, the Registered Nurse Case Manager performs daily
coordination of acute care with inpatient hospital staffing. The RN
Case Manager actively assists physicians and hospital staff in the
management of InnovAge admitted participants by facilitating care
through interaction with hospital departments and community
services. Review for medical necessity and level of care
appropriateness while coordinating post-hospital discharge
planning. The RN Case Manager collaborates with the
interdisciplinary team daily to coordinate appropriate plan of care
for post hospital visit for InnovAge PACE. Essential Functions and
Work Responsibilities Functional Category: Participant Nursing
Estimated Percent of time Spent - 70%
- Assesses, develops, plans, and evaluates care provided to
participants while admitted in hospital settings.
- Collaborates with physicians, 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 within the interdisciplinary team in the
formulation of 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
- Recommends alternative levels of care and ensures compliance
with federal, state, and local requirements.
- Assesses high-risk patients in need of post-hospital care
- Collaborate with hospital staff to develop and coordinate the
implementation of a discharge plan to meet participants identified
- Communicates the plan to physicians, patient,
family/caregivers, staff, and appropriate community agencies.
- Reviews, monitors, evaluates, and coordinates the patient's
hospital stay to assure all appropriate and essential services are
implemented timely and efficiently.
- Collaborate with the medical clinic to triage participants for
priority of care and routes accordingly. Oversees appointment
scheduling and ensures priorities are made based on participants in
- If required, visit participant in the hospital setting to help
coordinate care and discharge plan.
- Provides participants with education to assist with their
discharge and help them cope with psychological problems related to
acute and chronic illness.
- Responds to and performs coordination of care for admitted
- Oversees scheduling of appointments for post discharge care for
primary care visits.
- Assists in the examination, testing and treatment of
- Processes orders and disseminates orders and instructions to
appropriate personnel, in addition to implementing orders written
by primary care physician(s).
- Instructs participants and family regarding medications and
- Oversees scheduling of specialist appointments and assists in
hospital admissions and calling report to unit.
- Performs general nursing care to participants including
administering prescribed medications and treatments.
- Observes, records, and reports participant's condition and
response to medications and treatments to physicians.
- Documents all necessary information and maintains participant
medical record(s) and fulfills agency charting and reporting
requirements. Functional Category: Administration Estimated Percent
of time Spent - 30%
- Provides after hours on-call support to primary care providers
for hospital related discharges.
- Develops, implements, and maintains a current nursing care plan
in cooperation with the Clinic Nurse Manager.
- Coordinates transfer of patients to appropriate facilities;
maintains, and provides required documentation.
- Maintains and reviews participant records, charts, and other
- Request documents of in hospital stay and examination results
for participant records.
- Effectively communicates in interdisciplinary team meetings,
family meetings, and clinic meetings. Travel Requirements Travel
- Travel between local InnovAge worksites
- Travel to client and potential client homes and/or other off
- Overnight travel out of state
Keyphrases: gerontologist jobs, long term care nurse jobs, long
term care nursing jobs
Keywords: Total Community Options, Inc. dba Innovage, Roanoke , RN Case Manager (RN #), Healthcare , Roanoke, Virginia
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