Participant Manager RN

GENERAL DESCRIPTION: Under the direct supervision of the Clinic Manager, the Participant Manager provides direct participant care. Responsible for the daily coordination of participant care in the following areas: participant nursing assessments, nursing care plans, health education, maintenance, disease prevention and management of health care with appropriate documentation in the medical record. RESPONSIBILITIES: 1. Complete initial and routinely required nursing assessments of individual participants to include assessment of medication compliance. Initial assessments will be completed within ten days of participants’ enrollment. Routine reassessments will be completed by participants’ scheduled I/A date. 2. Completes participant reassessments and care plans due to changes in participant condition, as expeditiously as required by their condition. 3. Completes reassessments at the request of participant / or designated representative. 4. Develop the nursing care plan in conjunction with the team and provide documentation that meets the standards mandated by PACE, TDHS and nursing practice. 5. Function in the role of triage nurse to include calling participants who do not come to center because they are ill or who miss scheduled clinic appointments and documenting triage findings. 6. Work closely with physicians in the daily management of participant care to include maintaining a continuous flow of participants through the exam rooms, checking on sick participants in the treatment room and assisting with procedures as needed. 7. Interact and work with caregivers to coordinate participant care and respond to participant and caregiver phone calls to include providing education and counseling. 8. Coordinate hospital and Nursing Home admissions, discharges and transfers. 9. Interact and work closely with home health, medication and treatment nurses and personal care workers to coordinate comprehensive participant care. 10. Coordinates with participant, family, caregiver and contacted providers to ensure 24 hour service delivery. 11. Work closely with medical assistants to ensure all scheduled lab work and diagnostic tests are completed and on chart for the next scheduled clinic visit. 12. Documents in participants’ medical record as required by departmental policies and procedures. 13. Review and coordinate all consults and follow-up visits to include procedures and any needed medications. 14. Participate in all morning and I & A meetings as necessary and daily participant meetings. To include communicating participant changes. 15. May assume charge duties in the absence of the clinic manager. 16. Attend monthly clinic meeting and staff in-services. 17. Performs other duties as assigned by the Clinic Manager. QUALIFICATIONS: EDUCATION/EXPERIENCE A. A graduate of an accredited nursing program with a license to practice in the state of Texas as a Registered Nurse. B. One year of experience with a frail or elderly population preferred. KNOWLEDGE/SKILLS/ABILITIES A. Must possess a working knowledge of management theory and practice as well as nursing theory and practice. B. A dependable individual with a strong knowledge base and keen understanding and appreciation of the elderly. C. The ability to present to the community the philosophy of community-based long-term care for the elderly. D. The skill to work collectively and communicate effectively with staff, participants and family members. E. Adaptable individual with ability to work with the interdisciplinary team approach to care for the elderly. F. The ability to delegate responsibility as well as accept supervision in an appropriate manner. G. Processes good computer skills. H. Bilingual (English/Spanish).