Registered Nurse, PACE Enrollment

Family Health Centers of San Diego•San Diego, CA

1d•$50 - $62•Onsite

About The Position

Family Health Centers of San Diego (FHCSD) is hiring a Registered Nurse for PACE Enrollment. Under the supervision of the RN Manager, PACE Center, the nurse assesses whether prospective PACE participants can safely live independently in the community with PACE services. Using established evaluation tools and criteria, the nurse evaluates the safety and stability of the person’s living environment, determines PACE eligibility, and submits applications to the California Department of Healthcare Services (DHCS), attesting that the senior is appropriate for PACE. The role includes home assessments, coordination with prospective participants and their families or support persons, presentation of candidates to the interdisciplinary team, development and review of home care plans, and ongoing audits of home care and outsourced services. The position is regular, full-time, onsite in San Diego, with a Monday–Friday, 8 a.m.–5 p.m. schedule. Travel between sites and other locations is required.

Requirements

California State Board RN 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 diploma or GED equivalent.
Ability to travel between sites and other locations; must have a car, a valid California driver’s license, proof of required minimum car insurance, and an acceptable driving record.
Ability to work effectively in a team environment.
Demonstrated ability to communicate effectively and openly with interdisciplinary team members about participant status and needs.
Ability to multitask, be flexible, ensure accuracy, and meet changing priorities in a fast-paced, high-workload environment.
Basic computer literacy to meet department needs, including E-HR documentation, obtaining background information and reports, and following up on appointments.
Demonstrated commitment to community medicine and providing culturally competent care to medically underserved people.

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 and assess home safety, stability, and PACE appropriateness using established criteria and guidelines.
Determine whether prospective participants are enrolled in state-funded programs that could prevent PACE enrollment, including San Diego County in-home support services and DMH programs.
Explain disqualifying program enrollment to prospective participants and provide alternative resources when available.
Present prospective participants to the interdisciplinary team (IDT) for approval to proceed to a Level of Care assessment.
Provide individualized resources and education to prospective participants who are not eligible, including steps that may help them qualify for PACE.
Conduct in-home Level of Care assessments according to established guidelines.
Assess prospective participants’ goals and wishes regarding participation 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 approval to participate, 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 the home care needs assessment with the prospective participant and their family or support persons.
Review participant goals and wishes and determine whether they have changed.
Establish a home care plan of care with the prospective participant and their family or support persons before the participant signs the enrollment form.
After enrollment, collaborate with the home care supervisor to review the established home care plan for implementation.
Collaborate with the RN Manager to audit and review home care services for care-plan compliance at least every three months and update plans as participant goals or needs change.
Collaborate with the RN Manager to review outsourced home care and home health services weekly to confirm services are delivered as ordered and discontinued when appropriate.
Audit home health charts for completion.
Perform other duties as assigned.