DESCRIPTION:

1. Know, understand, incorporate, and demonstrate the Mission, Vision, Values and Guiding Behaviors of Trinity
   Health and Trinity Health PACE (TH PACE) in behaviors, practices, and decisions.
2. Consistently demonstrate (leads by example) TH PACE Values to all internal and external customers
   (participants, visitors, volunteers, and colleagues.) Create and maintain an atmosphere of warmth, propagating a
   calm environment throughout the office.
3. Execute assignments in a culture that is shared and collaborative across all divisions within TH PACE.
4. Reflects the skills knowledge and abilities serving in the role of a leader. Define and share a strategy and vision;
   align resources toward achievement of organization results; grow and sustain the organization; identify, lead, and
   embrace change.
5. Establish and/or maintain as a member of the leadership team a plan to achieve operating goals.
6. Promote and maintain collaborative relationships with managers, peers, direct reports and customers by
   effectively fostering a team environment, building consensus and resolving conflicts.
7. Maintain department budget, place orders for equipment and supplies as necessary. Identify financial
   vulnerabilities and make cost reduction recommendations as needed.
8. Evaluate, develop, mentor, coach, counsel and discipline department staff. Supports other personnel from other
   departments through coaching and mentoring to help achieve optimum standard of excellence. Addresses issues
   of concern through courageous conversation and notifies department manager of any interactions requiring
   attention.
9. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, TH PACE Corporate
   Integrity Program, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a
   manner that reflects honest, ethical and professional behavior.
10. In light of a disaster will know your disaster recovery, crisis management and business continuity plans and act
    within your role that is developed within the business continuity plan. Which may include working at another
    location, remotely from home, and maintaining constant contact with key personnel.
11. Attend and participate in scheduled training, in-service training, mandatory annual in-service training and
    educational classes as required/needed.
12. Participate as a member of the interdisciplinary team (IDT), including completion of initial medical history,
    physical exam, and functional nursing assessments of each new participant and semi-annual, annual, and
    unscheduled assessments; communicate changes in participant health or functional status to the interdisciplinary
    team members, and participate in development of the plan of care and coordination for 24-hour care delivery.
13. Acts as liaison between the interdisciplinary team (IDT), participants, caregivers and community agencies.
14. Actively serves on the Quality Assessment and Process Improvement (QAPI) Committee if required. Involved in
    the development and implementation of QAPI activities.
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15. Coordinate hospital discharges in conjunction with the interdisciplinary team (IDT) and attending physician.
    Communicates updates to family or caregivers as needed.
16. Perform home visits as needed to assess living environment and support system.
17. Maintain current written/electronic records and documents related to participant care.
18. Communicate, counsels and guides participants and families regarding service needs and concerns; makes referrals
    as appropriate.
19. Manage and facilitate coordination and collaboration of participant care will all clinicians and caregivers.
    Responsible for identification of need and utilization of clinical services.
20. Actively participates in the coordination of efforts towards survey preparedness. When necessary contribute to
    the plan of correction for department deficiencies.
21. Responsible for adherence to all regulations, both federal and state, which govern the operations of a PACE
    organization and a licensed adult day care center. Follow Occupational Safety and Health Administration (OSHA)
    guidelines.
22. Counsel and educate participants, families and staff on health related topics.
23. Actively serves on various committees that support the daily operations of the program.
24. Provide on-call coverage during center hours of non-operation, if applicable.
25. Communicate with weekend and afterhours on-call staff, following up on issues as necessary.
26. Maintain confidentiality of participant information.
27. Scheduling outpatient procedures.

MINIMUM QUALIFICATIONS:

• Registered Nurse (RN) with an active, unencumbered license in North Carolina. BSN preferred.
• Minimum of two years’ experience working with the geriatric population; one year of experience with frail or elderly individuals is preferred.
• CPR Certification required; valid driver’s license and proof of insurance.
• Strong clinical skills, attention to detail, and the ability to work independently.

POSITION PURPOSE:

The Nurse Case Manager is responsible for planning, coordinating, implementing, and evaluating health care and social services for participants in the PACE program. This role serves as the key liaison between the interdisciplinary team (IDT), participants, caregivers, and community agencies.

WHAT YOU WILL DO:

• Collaborate with the IDT to develop and implement comprehensive care plans.
• Conduct health assessments, including initial, semi-annual, and unscheduled evaluations.
• Coordinate hospital discharges and manage home visits to assess participant needs.
• Maintain up-to-date medical records and guide families in care decisions.
• Participate in quality improvement efforts and ensure adherence to all regulatory standards.