Homecare Care Manager, RN




Full Time

Mon-Fri, days

PACE (Program for All-Inclusive Care of the Elderly) is a community-based program which provides patients with all necessary health services while they stay in their homes. It covers many different types of services including a day center, personal care in the home, home based emergency response system, transportation to appointments, delivery of medical supplies, therapy, as well as inpatient services.

JOB SUMMARY: The PACE Care Manager RN under the supervision of the Home Care Manager performs the initial assessment, semi-annual assessment, annual reassessment and change of condition assessments of participants in the participant's home environment. Provides skilled nursing care, treatments, and health education to participants, families, and caregivers in the home and community setting (ALF, NF, Respite). Implements orders, develops appropriate plans of care for participants in their home, and supervises other in-home care staff members (LPNs, UCPs) in carrying out duties and responsibilities. The RN is assigned to oversee the review, authorization, care, transition planning and utilization of Emergency Department, Hospital and Skilled Nursing Facility services by PACE participants. This role coordinates the plan of care with appropriate community resources, the IDT and PACE Providers. Maintains the participant's medical record with thorough documentation. Communicates participant condition, plan and progress to team members and the IDT as appropriate. The RN must have strong communication skills and the ability to converse comfortably with patients, caregivers, physicians, community partners and the interdisciplinary team. The RN performs the core nursing functions of Assessment, Planning, Intervention and Evaluation. The position requires a high degree of flexibility, independence and willingness to participate in multiple activities with local travel.



Bachelor's Degree in Nursing - If hired, employee agrees to obtain his or her Bachelor of Science in Nursing (BSN) degree no later than 5 years (60 months) from date of hire.


· Licensed RN or board eligible by the State of Virginia or compact state.

· Must have or obtain BLS per departmental requirements.

· Current valid driver's license and acceptable driving record required upon hire and to be maintained throughout employment.

· Must have reliable transportation to make visits to patient's homes as needed.

· CPR Certification and First Aid training required and must be maintained current throughout employment.

· Case Management Certification preferred.




· Must have minimum of 1 year working experience with the frail and elderly population.

· A minimum of 3 years of RN nursing experience in healthcare, preferably in an acute, home care or long term care.

· 10+ years of LPN experience will be considered in lieu of 3 years of RN nursing experience.

· Experience in Care Management highly desired.

· Previous experience in Home Health, Skilled Nursing, Utilization Management, Discharge Planning, Disease Management or Health Coaching highly desired.



ADDITIONAL REQUIREMENTS: Able to manipulate computer proficiently. The ability to give patient injections, start IV's, change dressings, using fine motor skills, precise hand/eye coordination. Ability to use computer software applications to enter patient data into electronic medical record and view information in systems. Must be able to assess the patient's condition, formulate a plan of care, select appropriate interventions, evaluate patient response to care/ treatment, and to explain and teach patients about their condition/ recovery. Requires higher level of mental faculties accompanied by short term and long term memory. Ability to hear body system sounds, alarms and verbal orders. Ability to touch to distinguish change in patients. Ability to visually assess patient. Frequent exposure to body fluids, needle puncture wounds and communicable diseases; occasional exposure to chemotherapy and radiation. Personal injury due to moving and handling of patients. Ability to develop positive interactions with patients, families, physicians and staff in order to effectively care for the patient. Requires constant (activity that exists 2/3 or more of the time) walking and standing, pushing, pulling, stooping, lifting and ability to move throughout the facility in order to provide patient care. Must be able to respond in an emergency situation. Ability to use lifting techniques/equipment. Must be able to exert up to 20-50 pounds of force occasionally (activity that exists up to 1/3 of the time) and or 10-25 pounds of force frequently (activity that exists 1/3 to 2/3 of the time) and up to 10 pounds of force constantly to move objects.



HOURS: Primarily day shift Monday through Friday 8am-5pm, ability to work evenings and weekends to meet participant's home care needs.