PACE Registered Nurse

San Ysidro Health•Vista, CA

About The Position

This position contributes to the health and well-being of SD PACE participants as an interdisciplinary team (IDT) member by providing direct and indirect nursing care. The nurse applies advanced nursing knowledge and skills independently and collaborates with multiple IDT disciplines to support participant health and safety, including management of complex clinical situations. The role includes assessing participants, developing and implementing individualized plans of care, coordinating with participants, families, and other care professionals, and evaluating and documenting care. The nurse participates in IDT care planning, staff meetings, quality improvement activities, and leadership and staffing processes. Initial and periodic assessments, at least every six months, must be completed before scheduled team meetings, and participant status changes must be communicated to IDT members. The nurse may conduct assessments in participants’ homes and skilled nursing facilities, including initial evaluations, routine follow-ups, and as-needed visits. The position requires independent field work and travel to different sites; travel time is paid and mileage is reimbursed. The nurse must keep current with applicable regulations, participate in professional development, attend required meetings, and perform other related duties as assigned.

Requirements

Graduate of an accredited school of nursing.
Current license to practice as a Registered Nurse in California.
Current American Heart Association BLS certification; must maintain current BLS certification.
Excellent oral, written, and interpersonal communication skills; ability to read, write, and comprehend medical information and terminology and effectively present information verbally and in writing.
Demonstrated knowledge of the RN scope of practice.
Ability to provide high-quality care for geriatric patients and to work effectively in a team environment.
Good organizational and supervisory skills, and ability to handle difficult and unusual interpersonal situations effectively.
Meet the standardized competencies for the position established by San Diego PACE and approved by CMS.
Ability to be culturally sensitive, respect diversity, and work effectively with people of different cultures and socioeconomic status.
Service orientation, initiative, organization, and ability to prioritize and complete a large volume of work within strict deadlines while providing prompt, efficient, responsive customer service.
Knowledge of video conferencing software and Microsoft Office, including Word, Excel, and PowerPoint.
Knowledge of electronic health records such as EPIC, True Chart, or NextGen; EPIC EMR experience is listed under equipment used.
Comfort starting IV lines, administering IV medications, and monitoring them.
Comfort with acute care of frail adults, complex wound care, and care of cognitively impaired adults.
Ability to triage clinical symptoms and apply care paths and clinical interactive tools in patient evaluation and care before communicating with physicians.
Physical ability to reach, bend, stoop, crouch, kneel, and grasp; full range of motion; ability to lift 50 pounds and lift participants.
TB clearance and compliance with mandated vaccinations and boosters.
Completion of pre-employment requirements, including I-9, physical, positive background and reference check results, completed application, new-hire orientation, and pre-employment PPDs.
Ability to travel occasionally to other sites or locations in San Diego County.

Nice To Haves

Six months of experience working with frail and/or elderly people.
Knowledge of or experience in senior or elder care settings such as PACE, nursing homes, hospice, or adult day health care.
Nursing competency and familiarity with care paths and interactive tools commonly used in skilled nursing home settings.

Responsibilities

Collect participant data, complete required forms, identify and prioritize problems and needs, make referrals or arrange follow-up, interpret and record diagnostic results, and conduct advanced nursing assessments.
Develop plans of care using the nursing process, incorporating other IDT disciplines’ plans and continuing care needs; involve participants and families in care planning and goal setting; and refer participants to multidisciplinary support services.
Complete initial and periodic assessments, at least every six months, before scheduled team meetings, and communicate participant status changes to IDT members.
Provide treatments, procedures, and other care according to prescriptions, accepted nursing practice, and PACE care standards; explain procedures and coordinate participant and family education for around-the-clock care delivery.
Identify emergencies and independently initiate advanced therapy; coordinate care with other healthcare personnel and evaluate care measures.
Respect participant rights and use established mechanisms to address ethical issues in care.
Document care delivered, variations and their rationale, observations of actual or potential problems, and nursing measures taken.
Delegate nursing care appropriately, incorporate cost-effective measures, identify and document unit problems, participate in quality improvement, and comply with directives and policies concerning staffing and safe working conditions.
Report and monitor unsafe working conditions, identify ineffective or inappropriate care management, troubleshoot and resolve problems, complete written reports as necessary, fulfill assigned unit call, and adjust staffing for census and acuity.
Participate as an IDT member, attend staff meetings, and contribute to participant care planning.
Conduct timely assessments in participants’ homes, skilled nursing facilities, and other settings as needed to support care planning, PACE compliance, and participant safety and well-being.
Travel to different sites and work independently in the field; travel time is paid and mileage is reimbursed.
Keep abreast of regulations and standards and comply with orders or directives from government and regulatory agencies.
Support professional development through educational programs, current literature, in-service meetings, and workshops; attend required meetings and participate on committees as directed.
Perform other related duties as assigned or requested.