Registered Nurse, Care Manager-PACE

Neighborhood Healthcare•Riverside, CA

3d•$50 - $75•Onsite

About The Position

Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community. As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 100,000 people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants. The Registered Nurse Care Manager will establish a well-rounded care practice by incorporating patient assessment, implementing/coordinating care plans, and monitoring routine evaluations to ensure medically appropriate care. This role will facilitate Interdisciplinary Team (IDT) care coordination and intensive medical management for participants discharged from hospitals/skilled nursing facilities, and the implementation of skilled nursing services. Additionally, this position will work with the IDT Social Worker and Physician to collect necessary medical and social information to support comprehensive decisions that ensure participants' safety and well-being.

Requirements

Associate's degree in nursing required
Valid CA RN license required
Current Basic Life Support (BLS) certification through an American Heart Association (AHA)-approved source is required upon hire and must be maintained as a condition of employment
Current CPR and First Aid certification are required for all PACE employees in accordance with CMS and DHCS requirements.
1 year of nursing (clinical, outpatient, or general medicine) experience required
Valid driver's license required and maintained as a condition of employment
Active auto insurance required and maintained as a condition of employment
Excellent verbal and written communication skills, including superior composition, typing and proofreading skills
Ability to interpret a variety of instructions in written, oral, diagram, or schedule form
Ability to maintains acceptable standards of nursing care based on regulatory requirements
Ability to successfully manage multiple tasks simultaneously
Excellent planning and organizational ability
Ability to work as part of a team as well as independently
Ability to work with highly confidential information in a professional and ethical manner
Follow all safety procedures as outlined in Neighborhood Healthcare’s Illness and Injury Prevention Plan (IIPP) and report any injuries and/or unsafe conditions immediately
Maintain current knowledge of policies and procedures as they relate to safe work practices
Use appropriate body mechanics to ensure an injury free environment
Be familiar with location of nearest fire extinguisher and emergency exits
Follow all infection control procedures including blood-borne pathogen protocols
Maintain privacy of all patient, employee and volunteer information and access such information only on a need-to-know basis for business purposes
Comply with all regulations regarding corporate integrity and security obligations
Report all behavior and/or activity that are unethical, fraudulent, or unlawful

Nice To Haves

Bachelor's degree in nursing preferred
home or community health experience preferred
Bilingual (English/Spanish) highly preferred
Knowledgeable about and experience with adult day health center or PACE programs

Responsibilities

Manages the initial assessment for potential PACE participants, including home visits to support environmental and physical assessments
Coordinates and completes semiannual assessments with 1:1 at PACE Multipurpose Center and/or at participant's home for assigned case load
Documents activities encountered between participants, families, caregivers, contracted providers, hospitals, skilled nursing facilities (SNF), and other facilities working together to ensure the well-being of PACE participants in accordance with PACE policies, procedures, and regulatory requirements by providers
Ensures implementation and compliance of participants care as ordered by providers
Responds and manages medical emergencies based on necessary courses of actions dependent on the type of medical emergencies
Provides RN clinical coverage in the PACE clinic
Screens and triages participants, as needed
Documents nursing care on the day service is rendered in accordance to established guidelines related to medical care provision
Administers medications and treatments ordered by the physician/APP, including monitoring participant responses
Participates on the Interdisciplinary Team to assess the nursing needs for participants
Works with members of the interdisciplinary team (IDT), participants, and families in developing the plans of care for participants
Maximizes participant functional capacity by encouraging autonomy in all aspects of care
Educates, supervises, and counsels participants and/or caregivers regarding nursing care needs and other related problems
Educates participants and families in safe administration of medication for home use, including assessing and encouraging compliance with medication regimen
Initiates preventative and rehabilitative procedures or programs as appropriate for care and safety to participants
Notifies appropriate medical personnel and IDT of changes in participant statuses
Recognizes and understands the significance of abnormal test results to assist in gathering data, planning, and implementing care
Provides safe total patient care to participants with complex health problems with a focus on individual participants and their families
Maintains standards of nursing practice and follows hospital policies/procedures for care delivery and medication administration
Evaluates participant outcomes and or progress toward achieving the objectives/goals of the care plan and communicates this information to IDT members
Collaborates with IDT to revise the plan of care based on changes in participant physical or psychosocial status and initiates actions that are consistent with the changes in status
Works with participants, families, and IDT members to evaluate/measure the individual and group response to nursing care and teaching interventions, including documenting the outcomes of the problems identified at scheduled reviews
Maintains accurate and timely records of participant’s functional health status, progress toward care plan outcomes, revisions to care plans, care given, etc.
Advocates on behalf of participants and demonstrates accountability in resolving participant concerns or issues
Complies and promotes the participant bill of rights, including assessing and working towards achieving high levels of participant satisfaction
Keeps abreast of all regulations and standards to ensure compliance with orders or directives issued by duly constituted government/regulatory agencies
Enhances professional growth and development through participation in educational programs, current literature, in-service meetings, and workshops
Attends meetings and participates on committees, as directed