IDD Waiver Services RN Case Manager

The RN Case Manger will support individuals with an intellectual and/or developmental disability who reside in a community by providing clinical case management and oversight of client care. Clinical case management will support service provision focused on achieving client goals established by the person receiving services and/or his or her family while supporting medical needs and activities of daily living.

The Waiver Services Registered Nurse (I/DD) Coordinator will:

Perform skilled nursing services, clinical oversight, and clinical case management, including but not limited to:

• Provide ongoing clinical case management and assessment through phone calls and home visits to individuals and their families receiving DD Services at PASCO.

• Carry a caseload of clients receiving DD Services and serve as a clinical resource to clients.

• Establish and maintain relationships with assigned clients and Direct Service Providers.

• Provide ongoing education regarding medical care and health and safety techniques to individuals receiving services and their families.

• Provide education and detailed explanations to Direct Service Providers on clinical care, medication, disease process, and delegated nursing care.

• Assess Direct Service Provider proficiency in the client’s individual care needs and validate that Direct Service Provide can safely and legally carry out all duties assigned.

• Perform nursing delegation by Board of Nursing Regulations for physician-ordered skilled nursing tasks.

• Write individualized and client-specific clinical care plans aligned with Physician’s Orders/ recommendations for client care.

• Maintain effective open communication and collaboration with individuals receiving services and their families to manage, track, and report on the ongoing creation and management of all medical documentation, including managing changes and obtaining Physician Orders.

• Update the client’s Medication Administration Record as the need arises to incorporate new Physician’s Orders.

• Perform quarterly and annual delegation monitoring, care supervision, and medication administration record reconciliation.

• Thoroughly understand the client’s individualized Care Plans and amending Care Plans to reflect updated Physician’s Orders, as needed.

• During client onboarding, create a Medication Administration Record, identify skilled nursing tasks that require nurse delegation, and collaborate with I/DD Service Coordinators to generate care plans that address the client’s clinical needs.

• During client onboarding, gather and assess all medical supplies and assistive technology/equipment for individuals receiving services to research and create all needed individual protocols. Routinely assess for new or changed medical supplies/equipment/assistive technology and provide Direct Service Provider education to ensure safe client care.

• Be available during business hours to receive phone calls from clients, their families, and/or Direct Service Providers to answer clinical questions and provide appropriate recommendations for the next steps.

• Utilize Service Plans and medical documentation and gather assessment data to create, update, and manage nursing delegation protocols, Physician Orders, Medication Administration Records, Treatment Administration Records, Seizure Protocols and Tracking Records, G/J-tube Protocols and Tracking Records, and other medical documentation.

• Evaluate the client's response to psychotropic medications and communicate findings to physicians and other members of the client’s care team. Gather informed consent from the client and/or caregiver and provide appropriate documentation to the service coordinator.

Ensure high quality and high continuity of care by communicating and coordinating with I/DD Service Coordinators, physicians, and other members of the client’s care team, both orally and through documentation:

• In conjunction with the I/DD Intake and Service Coordinator, care coordination with Community Center Board Service Coordinators/Case Managers who manage the Children’s Extensive Services (CES), Supported Living Services (SLS), and Developmental Disabilities Comprehensive Services (DD), Waivers and Services.

• Complete Generalized Event Records: Observe, record, and report key information to appropriate supervisory personnel (wounds, infections, hospitalizations, etc.), the client's general physical and mental condition, and signs and symptoms that may indicate condition changes.

• Report client changes in condition to the Primary Care Provider and request updated Physician’s Orders, as appropriate.

• Proactively communicate any other issues, including (but not limited to) clinical questions or special circumstances, compliance questions or issues, etc., to the supervisor.

• Communicate and collaborate with the client’s internal and external care teams to ensure non-duplicated and effective care is delivered, which maintains or improves client outcomes.

Adhere to rules established by PASCO policies, State Regulations, and Federal Regulations:

• Maintain timely records of visits, contact documentation, and updated individuals receiving services information per PASCO policy and governing body rules and regulations. 

• Understand and comply with all appropriate HIPAA regulations and maintain strict client health care record privacy and confidentiality.

• Attend nurse meetings and companywide meetings. Assimilate information provided or proactively acquire information to incorporate new information into current practice.

• Complete and submit all required documentation per governing body rules and regulations and within established Agency guidelines.

Other duties as assigned to support quality service to individuals receiving services.

RN Case Manager will be measured on:

• Timeliness and accuracy of communication documentation, record retention and maintenance, Care Plan and Medication Administration Record creation and updates.

• Timely responsiveness by phone and/or email, identifying needs and providing quality follow-up to all intake and ongoing individuals receiving services and their families.

• Effective and timely communication and collaboration with cross-departmental teams.

• Ability to anticipate and respond to the needs of individuals receiving services within the employee’s responsibility limits.

• Field audit results

• Knowledge and skills relevant to the position regarding providing care and services to individuals receiving services.

• Quality of care metrics (infections, wounds, etc.)

• Individuals receiving services and their family’s customer service and satisfaction feedback on nurses’ performance.

Experience: 

• 1-year nurse experience in an acute care setting required

• 1-year nurse case management or home health nursing experience preferred

• 1-year of supervision experience in the health care industry preferred

• Intellectual and/or developmental disability services experience preferred.

• Experience working with, interviewing, and relationship-building with individuals receiving services and their families.

Education and/or Licenses: 

• Current license to practice as a Registered Nurse in the state of Colorado

• Bachelor of Science in Nursing

• Current CPR

• Must complete all training required by PASCO

Knowledge, Skills or Abilities: 

• Clinical Judgment: Ability to gather data about an individual receiving services and make judgments regarding when and what to report to the family and other care providers.

• Knowledge of therapeutic action, side effects, and interaction of medications

• Ability to operate a computer, familiarity with Microsoft products, specifically Outlook, and ability to receive and process work in an Electronic Health Record system

• Service: Ability to establish and maintain relationships with individuals receiving services and their families and provide professional, appropriate, compassionate, and empathetic support and services.

• Maintaining Commitments: Ability to fulfill commitments consistently, show up when promised, and maintain strong communication with all individuals receiving services, their families, and collaborating team members/partners.

• Collaboration: Ability to maintain a positive attitude, demonstrate flexibility, and balance self-interest and service of others' interests with the agency.

• Knowledge of State, Federal, and Licensing rules and regulations for waiver services and service delivery.

• Knowledge of unique issues related to service delivery for people with various disabilities.

• Ability to communicate effectively both orally and in writing.

• Ability to work with diverse populations of individuals and external agency community partners.

• Ability to work with a diverse population

Physical or Other Requirements: 

Medium detailed work:

• Requires walking or standing a significant amount of the time.

• Exerting up to 50 pounds of force occasionally, and/or up to 20 pounds of force frequently, and/or up to 10 pounds of force constantly to move objects.

• Requires stooping, kneeling, crouching, grasping, lifting, reaching, pushing

• Requires close visual acuity to perform an activity such as preparing and analyzing data and figures; viewing a computer terminal; extensive reading; visual inspection involving minor defects, small parts, and/or operation of machines (including inspection).

• Access to reliable transportation, either public transportation or an automobile, with a valid Colorado driver’s license and insurance

• Must complete all comp/training required by PASCO administration