RN Care Coordinator​/Clinical Care RN

Position: RN Care Coordinator/Clinical Care RN

Location: Portage, MI

TheProgram ofAll-InclusiveCare for theElderly (PACE) offers a variety of services, with many of them provided onsite at a PACE Center.

PACE is an alternative to nursing home care and – through an interdisciplinary care team (IDT) of physicians, nurse practitioners, nurses, social workers, therapists, van drivers, and aides – coordinates and provides preventive, primary, acute, and long-term care services, so older individuals can continue living in the community.

• Purpose
• Professional Development
• Paid Holidays
• PTO and Sick Time
• Internal opportunities for growth
• Team Support
• Competitive Pay
• Life insurance
• 403(b) Retirement Savings
• Employee Assistance
• And MORE!

Provides direct nursing care to participants, utilizing excellent critical thinking skills. This role works independently in the application of advanced nursing knowledge and skills and can manage complex clinical situations. Collaboration with both licensed and non-licensed personnel.

This role currently combines the responsibilities of two positions. As the organization grows, these duties are expected to transition into two separate roles.

• In Home Assessments
• Triaging emergent situations and able to remain independent in the application of advanced nursing knowledge
• Monitoring acute and chronic medical conditions in coordination with Primary Care Providers (PCPs)
• Utilizing care plans independently to provide clinic and home-based direct care
• Administers treatments, procedures and medications as prescribed to participants

• Routine monitoring of acute and chronic medical conditions following the participants’ goals of care
• Performs wound care and treatments as prescribed in the participants plan of care
• Medication review and administration, immunizations, routine monitoring of acute and chronic medical conditions, conducting initial and periodic assessments. Performs advanced nursing assessments using critical thinking skills. Administers treatments/procedures/medications and other care as prescribed and according to patient care standards, identifies emergency situations and independently initiates advanced therapy
• Performs assessments and actively participates in development of care plan
• Makes home visits on a regular basis to provide care and treatment as ordered by the PCP. This may include wound care, lab draws, nurse assessments, medication management/set up and other nursing tasks
• Performs on-call needs and determines immediate needs for participant as needed
• Works beyond normal working hours and on weekends and holidays, as necessary
• Must complete all required education and file requirements on time
• Documents in the participant’s medical record as required by policy
• Must care, support, and collaborate with everyone involved in the participant’s care including staff and the participant’s family using the participant centered care model.
• Keeps the leader informed of problems or issues
• Performs other duties as assigned

This position has no professional supervisory responsibilities

• Bachelor’s degree preferred in Science of Nursing;
  Associate degree required
• RN–Nursing Diploma or Degree from accredited School of Nursing or University
• Well-developed ability to show discretion and maintain confidentiality
• Strong communication skills, both written and verbal
• Minimum of one year of experience working with the frail, elderly, or long-term care population
• Minimum of one year home care experience is preferred
• Minimum of one year wound care experience preferred

• Must possess an unencumbered license to practice as a Registered Nurse in the State of Michigan
• Possess current CPR certification by AHA or willingness and able to obtain as offered by Senior Care Partners PACE
• Demonstrates our core values of compassion, integrity, teamwork, and excellence
• Support of Senior Care Partners PACE philosophy
• Must provide exceptional customer service in support of all staff, external partners, and participants
• Must…