Immanuel Case Manager RN - Full Time Days - Immanuel Pathways Central Iowa *May be eligible for a sign on bonus* in Windsor Heights, Iowa

Purpose of the Job:

The primary responsibilities of this job includes the coordination, facilitation, and transition of PACE participants who are admitted to the hospital, in short-term or skilled rehab care, or long term care. The Case Manager Registered Nurse (RN) is an advocate for the participant and the PACE program to ensure optimal delivery of quality participant care. Supports and lives out Immanuel’s Mission and CHRIST Promises.

Job Requirements

• Be legally authorized (currently licensed or if applicable, certified or registered) to practice the job’s functions and actions in the respective state in which he/she is employed.

• Only act within the scope of his/her authority to practice in the respective state in which he/she is employed.

• Agree to abide by the philosophy, practices, and protocols of the PACE organization.

• Job specific competencies for the Case Manager RN will be met prior to assuming participant care.

• Incumbent may be assigned at more than one PACE Pathways site to perform job duties.


Key Areas

Key Responsibilities and Duties of the Job

Case Management


  • Facilitates the exchange of relevant participant information to include but not limited to the participant file of life, facility admission orders, advanced and present directives and care plan between Immanuel Pathways and the contracted facilities to establish continuity of care.

  • Communicates with acute care, sub-acute and long-term care facilities regarding status of participants and discharge planning needs. Facilitates communication of related information daily to the Interdisciplinary Team (IDT) in the morning meeting or via email if there is a change in status.

  • Participates in Nursing Home rounding and care plan meetings for participants to monitor the status of and communicate with the IDT regarding participant care.

  • Collaborates with IDT and attending physician for discharge planning and coordinates participants’ discharges from facilities to home or to other facilities including transportation, equipment, supplies, arrangements for services and related authorizations.

  • Daily hospital rounding to facilitate and assist the IDT in communicating and collaborating with the hospital inpatient care management team.

  • Performs a visit to hospitals, SNF’s or participant’s homes within 24 business hours, or the next business day in the event of a weekend or Holiday admission to ensure participant and/or family needs are being met and questions are answered.

  • Documents care coordination information in the participant’s electronic health record (EHR) in a timely manner in accordance with Immanuel Pathways documentation standards.

  • Monitors status and services of participants at contracted facilities, to ensure participants are maintained in the most appropriate setting while promoting independence, safety and quality of care.

  • Collaborates with Immanuel Pathways Quality Managers on QAPI projects related to transitions of care services and related satisfaction survey outcomes.

  • Makes referrals, or collaborates with Social Work to make referrals, to other agencies or services as needed.

  • Documents in the EHR progress notes on the relevant and specialized nursing services he/she provides.

  • Develops relationships with discharge planners in the network.

  • Monitor participants weekly the first 30 days of transitioning from one care setting to the next including, but not limited to the nursing home admission or discharge and hospital discharges, to ensure seamless coordination of services.

  • Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants and families.

  • Analyzes skilled services, inpatient utilization and clinical data available to ensure appropriateness of medical necessity of services requested and received.

  • Identifies and escalates quality of care issues through appropriate channels.

  • Collaborates with inpatient medical team and skilled nursing team to secure appropriate options and necessary services.

  • Collaborates with Provider Relations Specialist to educate contracted vendors on the PACE philosophy and model of care.

Participant Care


Provides support to Clinic RN’s with all processes as needed.

Assists in treatment, examination and testing of participants as needed.

Assures certain health and personal care services are provided.

Educates participants, family and caregivers in regards to care, medications and treatments as needed.



Acts within the scope of his or her authority to practice.

Implements Exposure Control Plan.

Complies with Emergency Preparedness Plan.

Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants and families.

Participates in and supports Quality Improvement Initiatives.

Completes internal or external ISIS PACE Reviewer training.

Completes Security Review process for system access in the respective state in which he/she is employed.

Maintains up to date knowledge of system\process and communicates to IDT as applicable.



Participates in continuing education classes and any required staff and training meetings.

Maintains professional affiliations and any required certifications.

Travels between the various Immanuel Pathways Centers as needed.

Performs other duties as assigned or requested.


  • Bachelor’s degree in nursing preferred; professional nursing school graduate required.

  • Current License as a Registered Nurse (RN) in the respective state in which he/she is employed is required.


  • Two (2) years of nursing experience in a hospital, acute care setting, nursing home or community-based setting - preferably in a geriatric care setting.

  • One (1) year experience with case management and/or working with a multidisciplinary team in a healthcare setting.

  • One (1) year experience working with the frail or elderly population is required.

Other Requirements –

  • Possess job-specific competencies for Registered Nurse.

  • Must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.

  • Basic Life Support (BLS) current certification.

  • Must have a valid driver’s license, proof of insurance and have reliable means of transportation.

KSA- Knowledge Skills and Abilities-

  • Knowledge of physical, mental, and social needs of the frail elderly and their families.

  • Knowledge base of health care problems of the frail elderly.

  • Knowledge of nursing principles and practices with particular reference to the elderly.

  • Knowledge of medical equipment and instruments.

  • Knowledge of local and state healthcare and aging networks; in the respective state in which he/she is employed.

  • Knowledge of the various disciplines to assess the needs of the elderly population.

  • Skilled in written and oral communication.

  • Ability to maintain accurate records and to prepare clear and concise reports, correspondence and other written materials.

  • Skilled in establishing and maintaining effective working relationships with physicians, participants, co-workers, and the public.

  • Skilled in facilitating group interaction, decisions and implementation processes.

  • Ability to effectively and efficiently plan, prioritize and follow-up on delegated responsibilities.

  • Ability to apply creative problem-solving and critical thinking skills to complex issues.

  • Ability to chart via Electronic Health Records.

  • Proven experience and basic computer proficiency (internet, email, Microsoft Office).

  • Ability to work independently with minimum supervision.

  • Ability to plan effectively using proactive approach, keeping appointments and following through on commitments.

Posting Title: Case Manager RN - Full Time Days - Immanuel Pathways Central Iowa May be eligible for a sign on bonus

Job ID: 2018-2629

External Company URL:

Street: 7700 Hickman Road