PACE Registered Nurse

San Ysidro Health•El Cajon, CA

12h

About The Position

This position is responsible for contributing to the health and well-being of SD PACE participants as an interdisciplinary IDT team member, providing direct and indirect nursing care to participants. This position requires independent application of advanced nursing knowledge and skills, as well as collaboration with multiple disciplines of the IDT team to ensure the highest level of health and safety for beneficiaries, including managing complex clinical situations for which he/she is responsible. Essential Functions of the Job: Assessment: Collects patient data and completes required forms with appropriate responses according to unit standards; identifies patient’s overt problems/needs and sets priorities; identifies problems requiring further referral and/or follow-up; interprets and records latest diagnostic results; performs advanced nursing assessment using sound judgement and critical thinking skills. Planning Care: Develops a plan of care based on sound nursing process, incorporating the plans of other IDT disciplines and continuing care needs; includes the patient/family in developing or revising the plan of care and goal setting; makes referrals to multidisciplinary support services. Initial and periodic assessments (minimally every 6 months) to be completed prior to the scheduled team meeting. Communicates participant status changes to all IDT team members. Implementing/Managing Care: Care provided conforms to accepted practice standards for nursing and PACE programming; provides correct treatments/procedures and other care as prescribed and according to patient care standards; demonstrates understanding of age-related characteristics and needs of patients served; explains nursing procedures via appropriate formats; provides participant and family education in coordination of 24-hour (around the clock) care delivery; identifies emergency situations and independently initiates advanced therapy; acts as coordinator of patient care with other health care personnel and evaluates patient care measures instituted; understands and demonstrates respect for patient rights and utilizes established mechanisms for management of ethical issues in patient care. Evaluation: Records patient care delivered as planned and any variation, with appropriate rationale; makes and records observations related to impending or associated problems; implements nursing measures related to impending or associated problems. Leadership: Using nursing process, delegates nursing care to appropriate personnel; integrates cost effective measures into nursing practice; recognizes unit problems and takes responsibility for documenting same; demonstrates active participation in QI processes; complies with directives and SD PACE expectations to meet staffing needs based on patient care needs; complies with policies addressing safe working conditions; reports and monitors unsafe working conditions; recognizes inappropriate and/or ineffective patient care management, trouble shooting and problem resolution skills, completes written reports as necessary; fulfills call for unit as assigned and adjusts staffing for census (volume) and acuity. Participates as a member of the Interdisciplinary Team. Attends staff meetings and contributes meaningfully to participant care planning. Additional Duties and Responsibilities The nurse will occasionally be responsible for conducting timely and comprehensive assessments of participants in various settings, including their homes and skilled nursing facilities. These assessments may include initial evaluations, routine follow-ups, and as-needed visits to support care planning, ensure compliance with PACE requirements, and promote participant safety and well-being. The ability to travel to different sites and work independently in the field is essential. Travel time will be included as paid time, and mileage will be reimbursed. Keeps abreast of all regulations and standards to ensure compliance with orders or directives issued by duly constituted government / regulatory agencies. Enhance professional growth and development through participation in educational programs, current literature, in-service meetings and workshops. Attends meetings as required and participates on committees and directed. Perform other related duties as assigned or requested.

Requirements

Graduate of an accredited school of nursing
Current license to practice as a Registered Nurse in California
Current BLS (American Heart Association)
Excellent oral, written, and interpersonal communication skills
Ability to read, write and comprehend medical information and terminology
Ability to effectively present information, both verbal and written
Demonstrated knowledge of the RN scope of practice
Good interpersonal skills
Possess the skills to provide high quality care for geriatric patients
Must thrive in team environment, possess good organizational and supervisory skills, and have the ability to effectively handle difficult and unusual interpersonal situations
Meet a standardized set of competencies for the specific position description established by San Diego PACE and approved by CMS
Demonstrated ability to be culturally sensitive and respect diversity, work effectively with individuals of different cultures and socio-economic status; passion for service; self-starter and highly organized; ability to prioritize and complete a large volume of work within strict deadlines; provide prompt, efficient and responsive customer service
Knowledge of video conferencing software and Microsoft Office, including Word, Excel, and Power Point
Knowledge of Electronic Health Records (ie. EPIC, True Chart, Nextgen)
Physical clearance for reaching, bending, stooping, crouching, kneeling, and grasping; have full range of motion; ability to lift 50 lbs; need to lift and participants
TB clearance
Must maintain current BLS Certification
Frequent standing and walking
Will be required to occasionally travel to other sites or other locations in San Diego County
Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs
Compliance with all mandated vaccinations and boosters is a term and condition of employment

Nice To Haves

6 months experience working with the frail and/or elderly population
Knowledge and or experience working in senior or elder care setting – PACE, Nursing Home, Hospice, ADHC, etc.
Nursing competency and familiarity with care paths, interactive tools commonly used in skilled nursing home settings
Must be able to triage clinical symptoms, apply care paths and clinical interactive tools in patient evaluation and care prior to communications with physicians
Must be comfortable starting IV lines, IV medication administration and monitoring
Must be comfortable with acute care of frail adults, complex wound care, and cognitively impaired adults
EPIC EMR Experience

Responsibilities

Collects patient data and completes required forms with appropriate responses according to unit standards
Identifies patient’s overt problems/needs and sets priorities
Identifies problems requiring further referral and/or follow-up
Interprets and records latest diagnostic results
Performs advanced nursing assessment using sound judgement and critical thinking skills
Develops a plan of care based on sound nursing process, incorporating the plans of other IDT disciplines and continuing care needs
Includes the patient/family in developing or revising the plan of care and goal setting
Makes referrals to multidisciplinary support services
Communicates participant status changes to all IDT team members
Provides correct treatments/procedures and other care as prescribed and according to patient care standards
Demonstrates understanding of age-related characteristics and needs of patients served
Explains nursing procedures via appropriate formats
Provides participant and family education in coordination of 24-hour (around the clock) care delivery
Identifies emergency situations and independently initiates advanced therapy
Acts as coordinator of patient care with other health care personnel and evaluates patient care measures instituted
Understands and demonstrates respect for patient rights and utilizes established mechanisms for management of ethical issues in patient care
Records patient care delivered as planned and any variation, with appropriate rationale
Makes and records observations related to impending or associated problems
Implements nursing measures related to impending or associated problems
Using nursing process, delegates nursing care to appropriate personnel
Integrates cost effective measures into nursing practice
Recognizes unit problems and takes responsibility for documenting same
Demonstrates active participation in QI processes
Complies with directives and SD PACE expectations to meet staffing needs based on patient care needs
Complies with policies addressing safe working conditions
Reports and monitors unsafe working conditions
Recognizes inappropriate and/or ineffective patient care management, trouble shooting and problem resolution skills
Completes written reports as necessary
Fulfills call for unit as assigned and adjusts staffing for census (volume) and acuity
Participates as a member of the Interdisciplinary Team
Attends staff meetings and contributes meaningfully to participant care planning
Conducting timely and comprehensive assessments of participants in various settings, including their homes and skilled nursing facilities
Keeps abreast of all regulations and standards to ensure compliance with orders or directives issued by duly constituted government / regulatory agencies
Enhance professional growth and development through participation in educational programs, current literature, in-service meetings and workshops
Attends meetings as required and participates on committees and directed
Perform other related duties as assigned or requested