RN Clinical Care Coordinator
Status: Full-time, 40 hours/week
Schedule: Monday-Friday, 8:00a-4:30p
with on-call rotation
LifeCircles provides all-inclusive care to frail seniors in the community who desire to remain in their home but need additional support to achieve that goal. Geriatric appropriate clinical services are provided both in the onsite clinics and in participant’s homes. Be part of the innovative, creative, hardworking team providing stellar patient-centered care.
Join our team of compassionate and skilled team members and love your career!
Benefits: Be part of an organization that values their team members and knows the importance of providing a supportive community. Affordable and layered benefit plans for individuals that are hired for 30 or more hours/week, Retirement Savings Plan (with potential Company match), Wellness Initiative, Scholarship Program and Education Tuition Assistant, Paid Time Off, 6 Paid Holidays per year PLUS a paid Floating Holiday and a paid Birthday Holiday, DAILYPAY, and MORE!
DailyPay-Work Today, Get Paid Tomorrow!
The primary purpose of this position is to deliver participant centered nursing care for LifeCircles participants across all care settings. The Clinical Care Coordinator will use PACE appropriate assessments and interventions to assist the participant and their care partners to meet the goals of their Advance Care Plan, making continual adjustments as the participant's medical and psychosocial needs change throughout their enrollment. This position is independent in the application of advanced nursing knowledge and skills and manages complex clinical situations for which he/she is responsible. May supervise both licensed and non-licensed personnel.
In conjunction with the interdisciplinary Team (IDT), the Clinical Care Coordinator is responsible for assessing participant needs, recommending interventions, developing care plans, and implementing services.
Assessment: Facilitates the integration of new participants into LifeCircles healthcare delivery system, including: medication review and administration, immunizations, routine monitoring of acute and chronic medical conditions, conducting initial and periodic assessments in participant home acute and long-term care facilities, the PACE center, and other community settings, and completing required forms. Identifies participant's overt problems/needs and sets priorities; identifies problems requiring further referral and/or follow-up; interprets and records latest diagnostic results; performs advanced nursing assessments using critical thinking skills. Assesses needs in the home related to clinical and ADL/IADL supports. Promptly reports unusual findings to the primary care provider, supervisor and/or IDT.
Planning Care: Participates in IDT meetings. Functions as an active member of the IDT; communicates participant changes to team members and contributes to the development of the participant care plan across all care settings. In collaboration with the Home Care Coordinators, develops and monitors care plans for home health aides ensuring clinical and ADL needs are met.
Care Coordination: Administers treatments/procedures/medications and other care as prescribed and according to patient care standards; oversees and monitors participant medications, demonstrates understanding of age-related characteristics and needs of patients served; explains nursing procedures in appropriate forms; provides discharge teaching and helps coordinate transitions in care settings; identifies emergency situations and independently initiates advanced therapy; acts as coordinator of patient care with other health care personnel and evaluates patient care measures instituted; understands and demonstrates respect for participant rights and utilizes established mechanisms for management of ethical issues in patient care, and participates in the coordination of the participant's 24-hour delivery of care services. Coordinates with Home Care Coordinators and other team members for DME and medical supplied needed in the home setting (O2, hospital beds, incontinence supplies, wound care supplies ostomy supplies, tube feeding supplies).
Evaluation/Documentation: Documents in the participant's medical records as required by policy. Includes recording participant care delivered as planned and any variation, with appropriate rationale; makes and records observations related to impending or associated problems.
Leadership: Delegates nursing care to appropriate personnel. In collaboration and consultation with leadership, ensures all LifeCircles employed home care staff meet appropriate competencies. The Clinical Care Coordinator must observe the 7 C's of communication when delegating tasks to personnel: Clear, Concise, Concrete, Correct, Coherent, Complete, and Courteous. Supports and actively participates in QAPI processes to promote a safe work environment and the appropriate delivery of participant care.
Participates as on call nursing staff per on call policies and procedures.
Skills and Knowledge
Able to read, write, speak, and understand the English language.
Possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.
Function independently and have flexibility, personal integrity, and the ability to work effectively with older adults, personnel, and support organizations
Must be knowledgeable of current nursing practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care.
Must have proven leadership experience and skills with the ability to get along harmoniously with others in a team environment.
Must possess excellent communication skills with individuals of all ages, especially the geriatric population
Must be organized and able to complete tasks efficiently
Must possess strong sense of professionalism, good critical thinking, creativity, flexibility, and excellent problem-solving skills
Must possess high ethical standards
Must be comfortable in a self-directed environment
Proficient in Excel, Microsoft Office, Outlook, and electronic medical records
Know, teach and live out the Mission and Guiding Beliefs of LifeCircles, UMRC & Porter Hills.
Manage from a position of compassion, passion and servitude.
Customer Service is key to relationships within and outside the organization. Make this a program achievement.
Every effort has been made to identify the essential functions of this position. However, this in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.
High School Diploma
RN-Nursing Diploma or Degree from accredited School of Nursing or University
Current CPR certification (or willing to obtain as offered by LifeCircles)
Reliable transportation and current valid MI driver's license
Current immunizations and vaccines
This position may require occasional travel to Porter Hills main campus, other PACE Centers, conferences and seminars.
LifeCircles PACE is a federally funded program through CMS and the State of Michigan. All employees are expected to adhere to the Participant Rights.
LifeCircles PACE provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability or genetics in accordance with applicable federal, state and local laws.