Key Areas

Key Responsibilities and Duties of the Job

35% Participant Care

• Coordinates with the IDT to develop a comprehensive, person-centered plan of care for each participant that promotes independence in the community, management of health conditions, and prevention of acute care admissions.
• Oversees clinic workflow & scheduling.
• Assures clinic health care and personal care services are provided.
• Participates in Quality Improvement activities including utilization management, clinical reviews and work groups.  Collaborates with the IDT and management team in planning interventions to improve quality and cost effectiveness. 
• Assists in treatment, examination and testing of participants as needed.
• Monitors participant’s response to medical treatment plan and nursing interventions, and revises plan of care as necessary.
• Manages and reviews participant’s records, charts, pertinent information and direct reports documentation. 
• Maintains participants’ medical record and ensures the fulfillment of agency charting and reporting requirements.
• Performs or supervises the medication process from delivery through administration of prescribed medications and treatments in accordance with nursing standards. 
• Collaborates with other health care professionals and caregivers regarding provision of participant’s health care.
• Functions as a member of the IDT. Maintains regular attendance at and participants in IDT meetings; communicates participant changes, collaborates on care planning decisions and coordination for 24 hour care delivery.
• Actively collaborates with the IDT and Case Manager in managing participant transitions and discharge planning to ensure optimal management of health conditions and prevent readmission to acute care and nursing homes.
• Coordinates with IDT to develop a comprehensive care plan for each participant and to implement PACE services in a high-quality and cost-effective manner.
• Conducts an in-person comprehensive initial nursing assessment including problem identification and plan of care with new PACE enrollees as needed.
• Conducts an annual & semi-annual in-person nursing assessment and re-assessment as needed.
• Educates participants, family and caregivers in regards to care, medications and treatments.
• Serves as a liaison between Immanuel Pathways and contracted nursing facilities regarding clinical issues for participants in long-term care.

15% Staff Management

• Provides orientation, initial and annual competencies, evaluates performance of respective Clinic RN’s Medication LPN, Clinic LPN, and Medical Assistant.
• Performs competencies on appropriate Clinical and Participant Center staff as needed.
• Ensures that the job responsibilities, authorities and accountability of direct reports are defined and understood.  Ensures that clinic staff works within their scope of practice.
• Engages in team building.  Coaches and mentors staff.  Instructs and teaches staff as needed.  Trains clinic staff to function independently.
• Communicates with weekend and after hour staff, following up appropriately.
• Educates other staff members to emergency procedures and Infection Control prevention and provides information to other staff and caregivers about health concerns and conditions of participants.
• Manages time and attendance for clinic staff under their supervision, including paid time off approval and record-keeping.
• Arrange for coverage for employees out sick or on vacation.

35% Clinic Operations

• Manages flow of clinic, oversees appointment bookings, triaging and gate keeping in conjunction with primary care and staff.  Ensures timely and appropriate care of participants.
• Responds to and perform Triage of incoming telephone calls.  Oversees scheduling of outside appointments for participants when necessary.
• Oversees scheduling specialist doctor appointments and assists in hospital admissions and calls report to unit.
• Takes lead in effectively communicating with IDT and community agencies at meetings and throughout the day.
• Oversees and ensures signing off orders, ordering medications from pharmacy and disseminating orders and instructions to appropriate personnel.  Ensures implementation of physician orders.
• Coordinates participant care with outside contracted service providers – nursing homes, assisted living, lab, oxygen, etc.
• Manages and reviews participant’s records, charts, pertinent information and direct reports documentation. 
• Communicates with weekend and after hour staff, following up appropriately.
• Responsible for the hiring process of new or replacement staff.
• Educates other staff members to emergency procedures and Infection Control prevention.  Provides information to other staff and caregivers about health concerns and conditions of participants.
• Coordinates student clinical rotations.

10% Compliance

• Acts within the scope of his or her authority to practice.
• Follows all Immanuel Pathways policies and procedures.
• Participates in and supports Quality Improvement initiatives.
• Maintains the confidentiality of all company procedures, results and information about employees, participants and families.
• Handles potentially infectious specimens with appropriate biohazard precautions, and practices Universal precautions.
• Implements Exposure Control Plan.
• Responsible for tracking and maintaining infection & post exposure evaluation and participant surveillance reports.
• Maintains safe working environment.  Follows Immanuel Pathways Safety policies and procedures and OSHA safety Guidelines.
• Complies with Emergency Preparedness Plan.

5% Other

• Participates in continuing education classes and any required staff and training meetings.
• Maintains professional affiliations and any required certifications.
• Performs other duties as required or requested.