Nurse Case Manager (63017)

The Nurse Case Manager is a Licensed Practical Nurse (LPN) or Registered Nurse (RN) who provides direct clinical care, care coordination, and case management for approximately 15-20 individuals with medical fragility, Intellectual and Developmental Disabilities (IDD), and Mental Health (MH) diagnoses living in Pennsylvania group homes regulated under 6400 standards. The role combines hands-on nursing care with case management to ensure services are timely, person-centered, cost-effective, and aligned with individual needs. Responsibilities include clinical care such as obtaining weights and blood pressure, wound assessment, and catheter care; coordinating appointments and services; managing medication and equipment needs; supporting care transitions; and training direct support professionals (DSPs) to recognize emergencies and provide daily care that promotes positive health outcomes.

DUTIES AND RESPONSIBILITIES:

• Perform clinical tasks including, but not limited to, wound care, feeding pump support, fall-risk assessment, lung and abdominal exams, post-ER and post-hospitalization assessments, and troubleshooting catheters, feeding pumps, and adaptive durable medical equipment.
• Conduct comprehensive nursing assessments to identify medical, functional, behavioral, psychosocial, and support needs, along with related risks and barriers.
• Develop, implement, and update individualized care plans and nursing recommendations based on physician orders, assessments, individual goals, and changing needs.
• Train and coach staff on personal care, repositioning, vital signs, emergency recognition, and response to urgent medical situations, including 911 emergencies.
• Coordinate care with contracted nurses, physicians, specialists, therapists, hospital staff, and community providers to ensure continuity of care.
• Monitor health status and treatment response, follow up on recommendations, and adjust care coordination priorities to support safe transitions and positive outcomes.
• Obtain needed education and train staff on the proper use of prescribed adaptive equipment, nutrition plans, and required meal textures.
• Serve as the primary contact for physicians and specialists by preparing appointment paperwork and supplying relevant test results, referrals, authorizations, and treatment information.
• Maintain accurate, timely, and confidential documentation in the electronic health record, including medical history, case notes, assessments, appointments, and care coordination activity.
• Order new medications and refills through the pharmacy system, communicate medication changes, and confirm medications are received by the homes.
• Support and review medication administration record (MAR) documentation, observe medication administration, and provide feedback to ensure compliance and accuracy.
• Audit medications to ensure correct texture, preparation, and administration method.
• Educate individuals, families, medical decision makers, next of kin, and staff on diagnoses, treatment plans, medications, equipment, and available resources.
• Coordinate care during ER visits, hospitalizations, and discharges, communicate with hospital staff, update records with new orders, and ensure follow-up recommendations are implemented.
• Advocate for access to healthcare services, benefits, equipment, and community-based supports.
• Participate in team meetings, case conferences, quality improvement activities, and medical appointments as required.
• Keep electronic and paper charts current to support staff access to accurate information and promote health and safety.
• Completes HRST Clinical Reviews of those in their caseload and communicates changes to the team.
• Participate in rotating on-call duties as assigned.
• Perform other duties as assigned.