PACE Registered Nurse (RN) Care Manager

PacificSource Health Plans•Springfield, OR

About The Position

Looking for a meaningful way to make a difference in the lives of older adults? At Pacific PACE LLC, you will be part of a team that provides compassionate, coordinated care that helps participants live safely, independently, and with dignity. Our approach honors the whole person, and that includes the people who work here. At PACE, you will join colleagues who value respect, connection, and shared purpose. We create space for every team member to contribute their strengths, grow in their role, and feel supported in the important work of caring for our community. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to disability, veteran status, race, color, religion, sex, sexual orientation, gender identity, national origin, genetic information, age, or any other protected status. We are committed to reflecting the diversity of the communities we serve and creating a workplace where differences are celebrated and everyone can thrive. The PACE RN Care Manager is an advanced nursing role focused on improving the health and quality of life for older adults participating in the PACE Program. This position is responsible for providing comprehensive nursing oversight across ambulatory, home based, and community settings including optimizing health outcomes, maintaining independence, and honoring what matters most to PACE participants. The RN Care Manager offers holistic, proactive monitoring of chronic conditions, develops care plans, and performs intensive case management as indicated for high-risk, complex, or acute cases. This position manages a panel of assigned PACE participants in collaboration with the PACE interdisciplinary team.

Requirements

A minimum of 3 years of nursing experience in various healthcare settings is required.
At least 1 year of experience working with frail, older adults is required.
A Registered Nurse with a current, unrestricted Oregon state license is required.
Valid CPR certification (BLS or ACLS acceptable) required at time of hire.
Possesses thorough knowledge of community services, providers, vendors, and facilities available to assist members.
Demonstrates the ability to use computerized systems for data and document recording and retrieval.
Maintains a current clinical knowledge base.
Exhibits excellent interpersonal and communication skills.
Capable of working independently and as part of a team.
Proficient in electronic medical records systems.
Each member of the PACE organization's staff that has direct contact with participants must meet the following conditions:
Be legally authorized (for example, currently licensed, registered or certified if applicable) to practice in the State in which he or she performs the function or action.
Only act within the scope of his or her authority to practice.
Have 1 year of experience working with a frail or elderly population
Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently.
Be medically cleared for communicable diseases before engaging in direct participant contact.

Nice To Haves

Experience in care management, geriatrics, chronic disease management, home health, or long-term care preferred.

Responsibilities

Actively participate in the interdisciplinary team by offering clinical expertise in team planning, problem-solving, and processes.
Develop, implement, and coordinate individualized nursing care for participants using established procedures and policies.
Assess participants' conditions, request necessary diagnostic tests, and develop treatment plans across all care settings.
Case manage participant care as indicated for hospitalizations, post-acute care, transitions of care, behavioral health crises, and/or coordination for multiple services for severe health conditions.
Monitor patients, administer medications, and assist with medical procedures as needed.
Collaborate closely with the PACE IDT to develop comprehensive and compassionate participant care plans.
During periods of program scale, growth, or operational need, the RN Care Manager may also provide direct clinic-based nursing, ensuring continuity of care and operational stability while maintaining a primary focus on care management responsibilities.
Participate in compliance and quality improvement initiatives.
Educate participants on treatments, self-care, and disease prevention to empower them to manage their health actively.
Provide direct or indirect nursing care to participants at the clinic, in their homes or other care settings.
Communicate with participants and their families, offering emotional support and compassionate care.
Communicate and educate participants and their caregivers emphasizing Age-Friendly care.
Accurately document in the Electronic Health Record (EHR) in a timely manner.
Serve on various internal and external committees as required or designated.
Participate in team meetings, caregiver groups, and special events as needed.
Provide on-call coverage for direct patient care with other staff as needed.
Foster a safe and supportive environment conducive to the professional development of healthcare professionals.
Meet department and company performance and attendance expectations.
Follow privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
Perform other duties as assigned.