What are the responsibilities and job description for the Case Manager position at TALENT Software Services?
Role Summary
Join our dedicated team in San Jose and become a vital member of the Interdisciplinary Care Team at Client. You will collaborate with team members to deliver and manage all aspects of participant care. You will conduct required PACE assessments, develop individualized Care Plans, and address patient needs. Working in partnership with the Primary Care Provider, you will be responsible for delivering care across various settings, including centers, homes, and skilled nursing facilities.
Duties And Responsibilities
Required Skills & Experience
Required Education
Join our dedicated team in San Jose and become a vital member of the Interdisciplinary Care Team at Client. You will collaborate with team members to deliver and manage all aspects of participant care. You will conduct required PACE assessments, develop individualized Care Plans, and address patient needs. Working in partnership with the Primary Care Provider, you will be responsible for delivering care across various settings, including centers, homes, and skilled nursing facilities.
Duties And Responsibilities
- Take ownership of the outcomes and quality of care for assigned participants, working directly with the PCP and utilizing clinic resources.
- Conduct in-clinic, at-home, and virtual PACE assessments, educate participants and their support network, and perform follow-up visits.
- Develop and implement a discipline-specific plan of care in collaboration with the IDT, participants, and families.
- Identify participants' needs, determine priorities, and collaborate with the Primary Care Provider and other team members.
- Coordinate care for participants with high complexity, ensuring seamless transitions and preventing unfavorable outcomes.
- Attend to Clinical Inbox to ensure timely completion of orders, review test results, and communicate actions with participants.
- Perform and document ordered procedures and care in clinics or homes as required.
- Communicate participant changes to the interdisciplinary team and coordinate with the Complex Care Team on transitions of care.
Required Skills & Experience
- Minimum of two years of nursing experience in a clinical setting with a frail or elderly population.
- Nursing knowledge and skills necessary to treat frail, elderly participants and manage complex clinical situations.
- Highly motivated, self-directed, and able to make sound decisions in emergency situations.
- Excellent clinical, organizational, and communication skills.
- Ability to work independently with minimal supervision.
- Experience working with people from diverse backgrounds and cultures.
- Commitment to unlocking the full potential of our most vulnerable seniors.
- Bilingual English/Spanish preferred.
Required Education
- Graduate of an Accredited School of Nursing.
- Unencumbered RN License.
- BLS Certification.
