RN Home Care Coordinator

Family Health Centers of San Diego

1d•$48 - $59•Onsite

About The Position

For more than 55 years, Family Health Centers of San Diego’s (FHCSD) mission has been to provide caring, affordable, high-quality health care and supportive services to everyone, with a special commitment to uninsured, low-income and medically underserved persons. FHCSD is one of the top 10 largest federally qualified health centers (FQHCs) in the country. We operate more than 90 sites across San Diego County, including 29 primary care clinics, 23 behavioral health facilities, 10 physical rehabilitation clinics, nine dental clinics, five vision clinics, four outpatient substance use treatment programs, three mobile medical units, two mobile counseling centers, two urgent care centers, and a pharmacy. Our staff provides care to over 227,000 patients each year, of whom 91% are low-income and 29% are uninsured. FHCSD provides care to all. Services include, but are not limited to adult care, chronic disease management, pediatrics, comprehensive women’s care including obstetrics, dental, vision, case management, physical rehabilitation, speech therapy for children, vaccinations, infectious diseases, behavioral health, substance use counseling and a host of specialty services including cardiology, podiatry, endocrinology, dermatology, among others. FHCSD also offers supportive services to those who are unsheltered and in need of intensive case management. The breadth of our clinic locations, services and programs has grown over the last five decades, making us the largest community clinic provider of health care to the uninsured in the county and one of the top 10 largest community clinic organizations in the nation. We are also the largest health care safety-net provider, largest school-based health care provider and the largest mental health provider in the San Diego region.

Requirements

Current California state licensure as a Registered Nurse.
Current American Heart Association healthcare provider CPR (BLS), or Advanced Cardiac Life Support, Advanced Trauma Life Support, or Advance Resuscitation Training.
Traveling between sites and other locations is required as an essential function of the job. Must have a car, a valid California driver’s license, and proof of minimum levels of car insurance as required under California law, although limits of $100,000 are recommended. An acceptable driving record is also required. California law requires all drivers to obtain a valid California driver’s license within ten days of establishing residency. Mileage and other reimbursement governed by policy.
Minimum of one (1) year of documented experience working with a frail or elderly population required.
Minimum of two (2) years of demonstrated successful experience in home care; preferred in-home care management experience required.
Knowledge of the older adult population health care issues.
Clinical competency with the older adult population including physical and cognitive assessments required.
Ability to participate collaboratively with multi-disciplinary care team.
Knowledge of and ability to perform clinic-based/or hospital-based/or home-based nursing tasks.
Ability to work effectively with participants from diverse social, cultural and economic groups.
Must be able to multi-task, be flexible, ensure accuracy, and meet changing priorities in a fast-paced, high workload environment.
Basic computer literacy to comply with department needs and expectations (i.e., E-HR documentation, obtaining background information and reports, following up on appointments, etc.).
Ability to work effectively in a team environment.

Nice To Haves

Bilingual English/Spanish preferred.

Responsibilities

Manage the initial home care assessment for PACE participants to include home visits to support environmental and physical assessments.
Obtains home care services order (e.g., initial evaluation, PRN home visit, discharge home care order) from PACE medical providers. Orders must indicate the specific services to be rendered, and whether time-limited, intermittent or on an ongoing basis, and the frequency of the services required by the participant.
Accurately documents in EHR direct patient services, care coordination, and collaboration with medical providers and other disciplines, maintaining accurate and up-to-date records.
Initiates and updates home care plans to establish and maintain the participant's individualized Plan of Care, tailored to their unique needs and goals.
Ensures coordination and completion of reassessments every 6 months and as needed at participant’s home for assigned case load.
Act as a liaison between the participants and the interdisciplinary team members.
Provide individual health education on the disease process and medication compliance to include verbal and written handouts for their reference.
Ensures that schedules for FHCSD CNAs and PCAs are well coordinated and managed and proactively modifies schedules to ensure accuracy and maximize availability of resources.
Coordinates visits, considering the qualifications of the PCA and CNA as well as the participants’ level of care requirements.
Notifies participant and/or primary caregiver in advance of changes to scheduling.
Works with LVN Home Care to ensure coverage in the absence of CNAs or PCAs or in emergent situations.
Maintains confidentiality regarding participant, staff, contractor, and organizational information.
Attends and participates in staff meetings, in-services, projects, and committees as assigned.
Trains new CNAs and PCAs and coordinates shadowing opportunities during patient visits, promoting skill development and consistency in participant’s care delivery.
Participates in daily IDT meetings.
Adheres to and supports the center's PACE’s policies, practices, and procedures.
Ensures applicable regulatory and departmental standards are adhered to on an on-going basis (CMS, DHCS, etc.).
Reviews and sign-off on all Case Managed participant Care Plans, Initial, 6-month, Change of Condition, and Annual Assessments.
Performs other duties as assigned.