Nurse Case Manager

Trinity Health; United States; On-site; USD 51,000 - 77,000; Full time

Benefits offered by this job

Day-1 benefits

DailyPay

PTO

Tuition reimbursement

Vendor discounts

Job summary

Trinity Health PACE is seeking a Nurse Case Manager to plan, coordinate, implement, and evaluate comprehensive health and social services for participants. You will liaise with the interdisciplinary team (IDT), families, and community partners to ensure high-quality, person-centered care.

Join a collaborative team that values compassionate, coordinated care and ongoing education. The role includes on-call responsibilities, discharge planning, and active involvement in QAPI initiatives within the

Qualifications

• Graduate of an accredited Nursing program with active RN license.
• CPR certification required.
• At least 2 years of geriatric population experience.
• Minimum 1 year with frail or elderly population or willingness to train.
• Valid driver’s license and proof of insurance.

Responsibilities

• Model Trinity Health PACE mission, values and guiding behaviors.
• Coordinate assessments with the IDT and develop care plans.
• Coordinate 24-hour care delivery and discharge planning.
• Maintain accurate clinical documentation and compliance.
• Participate in QAPI initiatives and survey readiness.
• Mentor and support team members; manage budget and supplies.
• Provide education and participate in committees; on-call as needed.

Education

Nursing degree

BSN preferred

Job description

Employment Type:

Full time

Description:

1.Know, understand, incorporate, and demonstrate the Mission, Vision, Values and Guiding Behaviors of Trinity Health and Trinity Health PACE (TH PACE) in behaviors, practices, and decisions.
2. Consistently demonstrate (leads by example) TH PACE Values to all internal and external customers (participants, visitors, volunteers, and colleagues.) Create and maintain an atmosphere of warmth, propagating a calm environment throughout the office.
3. Execute assignments in a culture that is shared and collaborative across all divisions within TH PACE.
4. Reflects the skills knowledge and abilities serving in the role of a leader. Define and share a strategy and vision; align resources toward achievement of organization results; grow and sustain the organization; identify, lead, and embrace change.
5. Establish and/or maintain as a member of the leadership team a plan to achieve operating goals.
6. Promote and maintain collaborative relationships with managers, peers, direct reports and customers by effectively fostering a team environment, building consensus and resolving conflicts.
7. Maintain department budget, place orders for equipment and supplies as necessary. Identify financial vulnerabilities and make cost reduction recommendations as needed.
8. Evaluate, develop, mentor, coach, counsel and discipline department staff. Supports other personnel from other departments through coaching and mentoring to help achieve optimum standard of excellence. Addresses issues of concern through courageous conversation and notifies department manager of any interactions requiring attention.
9. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, TH PACE Corporate Integrity Program, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
10. In light of a disaster will know your disaster recovery, crisis management and business continuity plans and act within your role that is developed within the business continuity plan. Which may include working at another location, remotely from home, and maintaining constant contact with key personnel.
11. Attend and participate in scheduled training, in-service training, mandatory annual in-service training and educational classes as required/needed.
12. Participate as a member of the interdisciplinary team (IDT), including completion of initial medical history, physical exam, and functional nursing assessments of each new participant and semi-annual, annual, and
unscheduled assessments: communicate changes in participant health or functional status to the interdisciplinary team members and participate in development of the plan of care and coordination for 24-hour care delivery.
13. Acts as liaison between the interdisciplinary team (IDT), participants, caregivers and community agencies.
14. Actively serves on the Quality Assessment and Process Improvement (QAPI) Committee if required. Involved in the development and implementation of QAPI activities.
15. Coordinate hospital discharges in conjunction with the interdisciplinary team (IDT) and attending physician.
Communicates updates to family or caregivers as needed.
16. Perform home visits as needed to assess living environment and support system.
17. Maintain current written/electronic records and documents related to participant care.
18. Communicate, counsels and guides participants and families regarding service needs and concerns; makes referrals as appropriate.
19. Manage and facilitate coordination and collaboration of participant care will all clinicians and caregivers. Responsible for identification of need and utilization of clinical services.
20. Actively participates in the coordination of efforts towards survey preparedness. When necessary contribute to the plan of correction for department deficiencies.
21. Responsible for adherence to all regulations, both federal and state, which govern the operations of a PACE organization and a licensed adult day care center. Follow Occupational Safety and Health Administration (OSHA) guidelines.
22. Counsel and educate participants, families and staff on health-related topics.
23. Actively serves on various committees that support the daily operations of the program.
24. Provide on-call coverage during center hours of non-operation, if applicable.
25. Communicate with weekend and afterhours on-call staff, following up on issues as necessary.
26. Maintain confidentiality of participant information.
MINIMUM QUALIFICATIONS

1. Must be a graduate of an accredited Nursing Degree program and possess a current, unencumbered, active license
   to practice as a Registered Nurse in the state of PACE Organization. BSN preferred. Active CPR Certification
   required.
2. Minimum of two (2) years of demonstrated successful experience in related services with geriatric population.
3. Minimum of one (1) year of documented experience working with a frail or elderly population or if less than one
   (1) year of experience, must receive appropriate training from the PACE organization on working with a frail or
   elderly population upon hiring.
4. Valid driver’s license in good standing and proof of insurance required.
5. Must have the ability to perform standard clinical procedures according to established protocols and possess
   initiative, solid problem solving skills and a high level of accuracy and thoroughness in documenting the delivery of
   services.
6. State of North Carolina - Must have Employee Medical Statement that meets the requirements of the Standards
   completed prior to beginning employment, signed within previous 12 months by an MD, NP or PA, indicating that
   the employee has no illness or health condition that would pose a risk to others and can perform the duties assigned
   in the job.
7. Must be action-oriented, have business acumen, manage conflict well, be customer focused, have high decision
   quality, flexibility to adapt to ongoing change and have organizational agility. Ability to work with minimal
   supervision and exercise independent judgment.
8. Possess interpersonal skills to drive collaboration, commitment and productivity when working with crossfunctional teams, customers and end users. Must be comfortable functioning in a virtual, collaborative shared
   leadership environment.
9. Demonstrates superior written and verbal communication and presentation skills appropriate for audience
   comprehension. Well-developed communication skills, both written and oral, that may be used either in an on-site
   or virtual environment is required. Able to communicate effectively with individuals and groups representing
   diverse perspectives.

Nurse Case Manager Page 3 of 4
10. Comprehensive to expert proficiency with Microsoft product suite (MS Word, Excel, Power Point, etc.); basic
knowledge and experience with electronic mail and calendaring system. Knowledge of systems necessary,
experience preferred. Ability to type with speed and accuracy. Ability to use other software as required to perform
the essential functions of the job.
11. Possesses a high degree of personal accountability, responsibility and independent decision making abilities with
the skills to plan, organize, develop, implement and interpret programs, goals, objectives, policies and procedures
of the organization in line with mission, vision, and philosophy of TH PACE.
12. Excellent organizational skills. Ability to perform multiple duties and functions related to daily operations and
maintain excellent customer service skills. Ability to perform frequent detailed tasks and provide immediate
service with frequent interruptions. Ability to change and be flexible with work priorities. Strong problem solving
skills.
13. Ability to research, analyze and assimilate information from various on-site or virtual sources based on technical
and experience based knowledge. Must exhibit critical thinking skills and possess the ability to prioritize workload.
14. Position may require 25% of travel within the Centers geographic region

Nurse Case Manager – PACE Program

Position Overview
The Nurse Case Manager plays a key role in supporting participants within the PACE program by planning, coordinating, implementing, and evaluating comprehensive health and social services. This position serves as a critical liaison among the interdisciplinary team (IDT), participants, caregivers, and community partners to ensure high‑quality, person‑centered care.

Position Highlights and Benefits:

• Day-1 Benefits (Low-cost medical, dental, and vision insurance plans).
• Opportunity to get paid daily – through DailyPay
• Paid holidays and generous Paid Time Off (PTO)
• Up to $4,000 in tuition reimbursement annually
• Discounts with major vendors; AT&T, Verizon, Ford Motor Company, General Motors, Quicken Loans.

What You’ll Do

• Demonstrate and model the Mission, Vision, Values, and Guiding Behaviors of Trinity Health PACE.
• Foster a warm, collaborative, and compassionate environment for participants, families, and colleagues.
• Work closely with the IDT to complete assessments, identify care needs, develop care plans, and coordinate 24‑hour care delivery.
• Conduct home visits, support hospital discharge planning, guide participants and families on care needs, and manage service referrals.
• Maintain accurate clinical documentation and uphold all regulatory, ethical, and compliance standards.
• Promote interdisciplinary teamwork, participate in QAPI initiatives, and support survey readiness efforts.
• Mentor and support team members, contribute to department operations, and manage budget/supply needs.
• Provide education, participate in committees, and ensure continuity of care, including on‑call responsibilities as needed.

Minimum Qualifications

• Graduate of an accredited Nursing program with an active, unencumbered RN license (BSN preferred).
• CPR certification required.
• At least 2 years of experience working with the geriatric population.
• Minimum of 1 year of experience working with frail or elderly individuals (or willingness to complete PACE‑provided training).
• Valid driver’s license, reliable transportation, and proof of insurance.
• Strong clinical skills, problem‑solving ability, and attention to detail.

Join us in making a meaningful impact in the lives of older adults through compassionate, coordinated care.

Wage Range - 36.81-55.22

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.