Registered Nurse, PACE Enrollment

Family Health Centers of San Diego•San Diego, CA

4d•Onsite

About The Position

Family Health Centers of San Diego is seeking a Registered Nurse for PACE enrollment. Under the supervision of the RN Manager, PACE Center, the RN evaluates prospective participants’ ability to live safely and independently in the community with PACE services. The nurse uses established tools and criteria to assess eligibility, home safety and stability, and level of care, and submits required applications and forms to the California Department of Health Care Services (DHCS) through the RN Manager. The RN supports prospective participants throughout enrollment by identifying disqualifying state-funded program enrollment, explaining eligibility criteria, providing alternative resources, presenting candidates to the interdisciplinary team, and assessing participants’ goals and wishes. After program approval, the RN determines home care needs, collaborates with participants and their support people to establish a home care plan before enrollment, and works with the home care supervisor and RN Manager to monitor and update services and plans of care. This is a regular, full-time, onsite position in San Diego, California, with a Monday–Friday, 8:00 a.m.–5:00 p.m. schedule. Travel between sites and other locations is required. The position offers a stated salary range of $50.00–$61.86 and an extensive benefits package. The successful candidate will demonstrate a commitment to community medicine and culturally competent care for medically underserved populations.

Requirements

California State Board Registered Nurse license.
One to two years of experience working with the older adult population.
Current American Heart Association healthcare provider CPR (BLS), or Advanced Cardiac Life Support, Advanced Trauma Life Support, or Advanced Resuscitation Training.
Graduation from a recognized RN/BSN program.
High school graduate or GED equivalent.
Ability to travel between sites and other locations as an essential job function.
Must have a car, a valid California driver’s license, proof of minimum car insurance required under California law, and an acceptable driving record. The posting recommends insurance limits of $100,000.
Ability to work effectively in a team environment and communicate openly and effectively with interdisciplinary team members about participant status and needs.
Ability to multitask, be flexible, ensure accuracy, and manage changing priorities in a fast-paced, high-workload environment.
Basic computer literacy to meet department needs, including electronic health record documentation, obtaining background information and reports, and following up on appointments.

Nice To Haves

Clinical competency with the older adult population, including physical and cognitive assessments.
Experience in home health care.
Bilingual English/Spanish.

Responsibilities

Accompany the Business Development Representative to initial home contact meetings.
Assess the safety and stability of prospective participants’ home environments and determine PACE appropriateness using established criteria and guidelines.
Determine whether prospective participants are enrolled in state-funded programs that could preclude PACE enrollment, including San Diego County in-home support services (IHSS) and DMH programs.
Explain that prospective participants cannot be submitted for PACE until they disenroll from disqualifying state programs, and provide alternative resources when available.
Present prospective participants to the interdisciplinary team for approval to proceed to a level-of-care assessment.
Provide individualized resources to people who are not eligible for PACE and educate them about steps that might qualify them for future enrollment.
Perform in-home level-of-care assessments for prospective participants according to established guidelines.
Assess prospective participants’ goals and wishes for participating in PACE.
Complete the DHCS level-of-care and certification forms and submit them to the RN Manager for review and submission to DHCS.
After program approval, determine home health and home care needs in an hours-of-care format using assessment data, observations, the home care service/hour tool, and clinical judgment.
Participate in pre-enrollment mini-assessments to review home care needs with prospective participants and their family members or support people.
Review participant goals and wishes, confirm they have not changed, and establish a home care plan of care with the prospective participant and their support people before the enrollment form is signed.
After enrollment, collaborate with the home care supervisor to review the established home care plan for implementation.
In collaboration with the RN Manager, audit and review home care services for care-plan compliance at least every three months, and update plans as participants meet goals or need new goals.
In collaboration with the RN Manager, review outsourced home care and home health services weekly to ensure services are delivered as ordered and discontinued when appropriate.
Audit home health charts for completion.
Perform other duties as assigned.