Care Transition Nurse Manager

Overview

Are you a Care Transition Nurse Manager passionate about coordinating exceptional care and helping older adults remain independent in their homes and communities? Join Immanuel Pathways PACE® , where you'll partner with a collaborative interdisciplinary team dedicated to improving participant outcomes, enhancing quality of life, and ensuring seamless transitions of care.

Immanuel Pathways PACE® is seeking a Care Transition Nurse Manager to work at Pathways Omaha , located at 5755 Sorensen Parkway, Omaha, NE 68152 .

Schedule Summary: Full-time days, Monday through Friday, with an on-call rotation every six weeks.

Schedule

• Monday through Friday, 8:00 AM - 5:00 PM
• Participate in a 7-day on-call rotation approximately every 6 weeks

Pay will be based upon experience, certifications, skills, and education.

This role offers the opportunity to make a meaningful impact by coordinating care transitions, collaborating with an interdisciplinary team, and supporting older adults in maintaining their independence and quality of life.

Best in Class Benefits can be found at Immanuel

• HEALTH : Medical, dental, vision, Health Savings Account (HSA), and Flexible Spending Account (FSA)
• LIFE INSURANCE : Employer Paid Life Insurance
• TIME OFF : Paid Time Off - accruing from day one of employment, Floating Holidays, Paid Holidays, 8 hours of Volunteer Time Off per year
• RETIREMENT : 401K with employer match
• WELLNESS : Wellness Program and Employee Assistance Program
• GROWTH AND DEVELOPMENT : Advancement opportunities (as appropriate) – we look to grow from within our organization, Education Assistance Program – we invest up to $5,250 per year for education assistance paid up front
• Plus many more benefits!

Job Duties & Skills Required

What You Will Do

The primary responsibilities of this job includes the coordination, facilitation and transition of Immanuel Pathways PACE program participants who are admitted to the hospital, in short-term or skilled rehab care, or long term care. The Case Manager Registered Nurse (RN) is an advocate for the participant and the PACE program to ensure optimal delivery of quality participant care.

Case Management

85%

• Facilitates the exchange of relevant participant information to include but not limited to the participant file of life, facility admission orders, advanced and present directives and care plan between Immanuel Pathways and the contracted facilities to establish continuity of care.
• Communicates with acute care, sub-acute and long-term care facilities regarding status of participants and discharge planning needs. Facilitates communication of related information daily to the Interdisciplinary Team (IDT) in the morning meeting or via email if there is a change in status.
• Participates in Nursing Home rounding and care plan meetings for participants to monitor the status of and communicate with the IDT regarding participant care.
• Collaborates with IDT and attending physician for discharge planning and coordinates participants’ discharges from facilities to home or to other facilities including transportation, equipment, supplies, arrangements for services and related authorizations.
• Daily hospital rounding to facilitate and assist the IDT in communicating and collaborating with the hospital inpatient care management team.
• Performs a visit to hospitals, SNF’s or participant’s homes within 24 business hours, or the next business day in the event of a weekend or Holiday admission to ensure participant and/or family needs are being met and questions are answered.
• Documents care coordination information in the participant’s electronic health record (EHR) in a timely manner in accordance with Immanuel Pathways documentation standards.
• Monitors status and services of participants at contracted facilities, to ensure participants are maintained in the most appropriate setting while promoting independence, safety and quality of care.
• Collaborates with Immanuel Pathways Quality Managers on Quality Improvement projects related to transitions of care services and related satisfaction survey outcomes.
• Makes referrals, or collaborates with Social Work to make referrals, to other agencies or services as needed.
• Documents in the EHR progress notes on the relevant and specialized nursing services he/she provides.
• Develops relationships with discharge planners in the network.
• Monitor participants weekly the first 30 days of transitioning from one care setting to the next including, but not limited to the nursing home admission or discharge and hospital discharges, to ensure seamless coordination of services.
• Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants and families.
• Analyzes skilled services, inpatient utilization and clinical data available to ensure appropriateness of medical necessity of services requested and received.
• Identifies and escalates quality of care issues through appropriate channels.
• Collaborates with inpatient medical team and skilled nursing team to secure appropriate options and necessary services.
• Collaborates with Provider Relations Specialist to educate contracted vendors on the PACE philosophy and model of care.

Participant Care

5%

• Provides support to Clinic RN’s with all processes as needed.
• Assists in treatment, examination and testing of participants as needed.
• Assures certain health and personal care services are provided.
• Educates participants, family and caregivers in regards to care, medications and treatments as needed.

Compliance

5%

• Acts within the scope of his or her authority to practice.
• Implements Exposure Control Plan.
• Complies with Emergency Preparedness Plan.
• Participates in and supports Quality Improvement Initiatives.
• Completes internal or external ISIS PACE Reviewer training.
• Completes Security Review process for system access in the respective state in which he/she is employed.
• Maintains up to date knowledge of system\process and communicates to IDT as applicable.

Other

5%

• Participates in continuing education classes and any required staff and training meetings.
• Maintains professional affiliations and any required certifications.
• Travels between the various Immanuel Pathways Centers as needed.
• Performs other duties as assigned or requested.

Skills & Requirements

Bachelor’s degree in nursing preferred; professional nursing school graduate required.

Current License as a Registered Nurse (RN) in the respective state in which he/she is employed is required.

Two (2) years of nursing experience in a hospital, acute care setting, nursing home or community-based setting; preferably in a geriatric care setting.

One (1) year experience with case management and/or working with a multidisciplinary team in a healthcare setting.

One (1) year of experience working with the frail or elderly population required, or completion of job specific training related to working with the elderly population must be completed within the first six months of hire.

Must have a valid driver’s license, proof of insurance and have reliable means of transportation.

Immanuel

At Immanuel, we believe that our success is built on the collective strength of our people. Here’s why you’ll thrive as part of our team:

• Meaningful work: You won’t just have a job; you will have a purpose. Our Mission impacts the lives of our residents/participants and their families, one another, and our community.
• Growth Opportunities: We invest in your development. Whether it’s mentorship, training, or advancement, we’re committed to your growth.
• Inclusive Culture: We celebrate uniqueness and foster an environment where everyone feels valued.
• Work-Life Harmony: We believe in allowing you to thrive by leveraging your passion. Achieve your best work while maintaining a healthy work-life harmony.
• Total Rewards: A focus on feedback and recognition, competitive compensation, a robust benefits package, and perks beyond the basics.
• Intentional Experience: We are very intentional about your employee experience, from Day One Orientation to how we onboard new managers and invest in quarterly and annual leadership training.

Join us at Immanuel and be a part of something extraordinary. Your journey starts here.

• Immanuel is an Equal Opportunity Employer and participates in E-Verify.
• A background check and drug screen will be required prior to hire.
• Applicants must be currently authorized to work in the United States on a full-time basis.