PACE RN Case Manager - $5,000.00 sign on bonus

Gary and Mary West PACE • San Marcos, CA

25d

About The Position

Join the Team Voted Best Place to Work in North County! Why Work for Gary and Mary West PACE? Because you're looking for more than just a job - you want work/life balance and the opportunity to make a meaningful impact in the lives of North County seniors and their families. At Gary and Mary West PACE, we support your personal and professional well-being with: Generous pay and a comprehensive benefits package focused on your health and wellness. 11 paid holidays, 13 days of PTO, and 5 days of sick time. A 5% employer match to our 403(b) retirement plan. No on-call time - because your time matters. We invest in our team with an annual education allowance and a commitment to professional growth, helping you expand your skills and advance your career. You'll thrive in a supportive, mission-driven culture where collaboration feels like family. As part of our multi-disciplinary team, your voice is heard, and your work is truly valued. Join us and do your best work-because here, your contribution matters. About PACE: Philanthropists Gary and Mary West founded West Health with the mission of enabling seniors to successfully age in place with access to high-quality, affordable health and support services that preserve and protect their dignity, quality of life, and independence. The Gary and Mary West PACE (Program of All-inclusive Care for the Elderly), affiliated with West Health (www.westhealth.org), is a non-profit that delivers medical, social, and behavioral services to the frail elderly to the North County of San Diego. This PACE center is entrepreneurial in nature and focuses on innovations and bringing new processes to the traditional PACE environment. We're looking for passionate healthcare providers who want to be part of a team dedicated to enable seniors to live in their communities as independently as possible by providing compassionate, comprehensive health and supportive care. One Team One Mission Position Summary: The Gary and Mary West PACE (GMWP) RN Case Manager provides case management for assigned participants. Utilizes clinical expertise, communication, and problem-solving skills to achieve optimal clinical and resource outcomes. Promotes quality of care by minimizing fragmentation, maximizing coordination, and facilitating participant movement through the health care organization. Performs patient needs assessments upon admission and at regular intervals, facilitating referrals and providing linkages to health, wellness, and post-acute care resources across the health care continuum. Promotes interdisciplinary collaboration and teamwork to progress the plan of care and discharge plan. Promotes appropriate length of stay, resource management, and care transitions to the next level of care. Must comply with all federal and state regulations surrounding the discharge process.

Requirements

• Graduate of an accredited school of nursing; Bachelor of Science (BSN)preferred.
• Unencumbered California Registered Nurse (RN)License.
• Current Basic Life Support (BLS) / First Aid Certification required
• Current Driver's license and proof of auto insurance.
• Minimum of two years nursing experience in a clinical setting with a frail or elderly population.
• Nursing knowledge and skills necessary to treat frail, elderly participants and manage complex clinical situations.
• Highly motivated, self-directed, able to execute tasks in a quickly changing environment and make sound decisions in emergency situations.
• Excellent clinical, organizational and communication skills in settings with seniors, their families and interdisciplinary team members.
• Experience and competency working with people from diverse backgrounds.
• Commitment to unlocking the full potential of our most vulnerable seniors.
• Employees must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
• Job offers are contingent upon a successful pre-employment drug screen, background check, and physical assessment.

Nice To Haves

• Bilingual Spanish-English preferred.

Responsibilities

• Performs daily coordination of care with inpatient hospital and/or the RCFE staffing.
• Actively assists providers, hospital, and RCFE staff in the care management of affected PACE participants by establishing and facilitating regular and ongoing channels of communication.
• Assesses participants for medical necessity and level of care appropriateness while facilitating level of care transitions, i.e., hospital to home/RCFE or home to RCFE.
• Collaborates with providers, other members of the interdisciplinary health care team, participants, and caregivers, in the development, implementation, and documentation of appropriate, individualized plans of care to ensure continuity, quality, and appropriateness of resources.
• Participates in the interdisciplinary team to formulate Plans of Care for PACE participants, as well as in other interdisciplinary team settings that plan, coordinate and monitor the care of PACE participants in institutionalized settings.
• Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.
• Ensures PACE plan of care is communicated and adhered to by the contracted RCFEs where PACE participants reside through regularly established joint conference meetings
• Provides or coordinates PACE or Participant-related education to the contracted RCFEs.
• Acts as the liaison between PACE and contracted RCFE facilities to assure all appropriate and essential services are implemented timely and efficiently for PACE participants.
• Oversees the coordination of specialty appointment, Day Center, and other scheduling needs for the participants residing in RCFEs.
• Conduct regular visits (as appropriate) to contracted RCFEs where PACE participants are residing to facilitate care-coordination.
• Provides general nursing care to participants as needed, including administering prescribed medications and treatments.
• Observes and reports participants' condition and response to medications, treatments, and other interventions to the IDT.
• Documents all necessary information in the EMR and maintains participant medical record(s), per PACE policies and procedures.
• Develops, implements, and maintains a current nursing care plan for participants residing in RCFEs, in cooperation with the Clinic Nurse and the IDT.
• Maintains accurate medical records from hospitalizations and any other transitions of care for participants residing in RCFEs, including the management of documents of in hospital stay and examination results for participant records.
• Communicates effectively with the participants, interdisciplinary team, family members and caregivers, and others
• Other duties as assigned.

Benefits

• Generous pay and a comprehensive benefits package focused on your health and wellness.
• 11 paid holidays, 13 days of PTO, and 5 days of sick time.
• A 5% employer match to our 403(b) retirement plan.
• No on-call time - because your time matters.
• We invest in our team with an annual education allowance and a commitment to professional growth, helping you expand your skills and advance your career.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level