JOB SUMMARY:

The RN Care Manager is responsible for ensuring high-quality, person-centered care by managing and coordinating resident needs across clinical, social, and behavioral aspects of care. This role involves collaboration with interdisciplinary teams, compliance with regulatory requirements, and supporting residents and families to enhance quality of life.

QUALIFICATIONS:

• Registered Nurse (RN) license in good standing.
• Certified in CPR.
• Strong organizational, interpersonal, and communication skills.
• Experience in behavioral health, care planning, and regulatory compliance preferred.
• Proficient in using electronic health records (EHR) systems, particularly PCC.

• Resident Admissions & Care Planning:
• Develop baseline care plans, including the social services component.
• Conduct and document skilled assessments, including follow-up and discharge notes for changes in the level of care.
• Medication Management:
• Administer and monitor antipsychotic medications and follow up as needed.
• Work with the pharmacy on Gradual Dose Reductions (GDRs) for psychotropic medications.
• Activate and monitor psychotropic medication orders in PCC.
• Social Services Support:
• Handle PASRR evaluations and submit monthly Level II reports.
• Complete the social services portion of the Minimum Data Set (MDS).
• Address grievances, resident rights education, and Ombudsman relations.
• Coordinate Advance Directives and assist residents in purchasing personal items.
• Behavioral Health & Resident Rights:
• Oversee behavioral health needs, risk management meetings, and behavior plans.
• Monitor smoking programs, conduct assessments, and ensure safety compliance.
• Appointments & Community Referrals:
• Coordinate appointments and transportation, including driving the van as necessary.
• Arrange referrals to community resources such as Gateway and MAO clinics.
• Organize post-discharge follow-up visits for residents returning home.
• Family & Resident Engagement:
• Facilitate care plan meetings and invite families.
• Lead Family Council initiatives and maintain effective communication with residents and families.
• Compliance & Documentation:
• Ensure regulatory compliance, including completing 671 forms (Medicaid).
• Manage resident notifications (e.g., room changes, significant changes, discharges).
• Photograph residents for the Electronic Medical Record (EMR).
• Equipment & Supply Management:
• Order Durable Medical Equipment (DME) and input orders into PCC.
• Training & Staff Collaboration:
• Provide dementia training for staff.
• Collaborate with behavioral health professionals and social services teams.
• General Duties:
• Serve as Manager on Duty and participate in the on-call rotation.
• Assist with resident admissions.