SUMMARY OF POSITION:
Under the direct supervision of the Center Manager, the PACE Community Services Nurse is responsible for assessing medical level-of-care eligibility for prospective PACE enrollees, and for assessing and implementing a plan for community-based caregiving services. He/she is one of the first introductions for prospective PACE enrollees to the PACE Interdisciplinary Team (IDT) and works in partnership with the Enrollment Specialist to ensure a smooth and successful transition into the PACE program.
ESSENTIAL JOB FUNCTIONS:
• Completes level-of-care documentation and submits for review to the Department of Health Care Services (DHCS), initially for prospective PACE enrollees and as required annually for enrolled Participants.
• Presents prospective enrollee cases to the Interdisciplinary Team (IDT), as needed.
• Participates as an active member of the IDT for Participant care planning.
• Conducts comprehensive nursing assessments, reassessments, and in-home evaluations on prospective or enrolled PACE participants developing and documenting care plan services and/or enrollment recommendations.
• Coordinates with the IDT to develop an individualized in-home Care Plan.
• Collaborates with the Home Care Supervisor to oversee the implementation and continuation of care plan services in the participant’s home.
• Ensures all participant changes are documented appropriately in the medical record and communicates participant changes to IDT in a timely manner.
• Assists with identifying qualifications and competency requirements for caregiving staff, and in providing training and competency checks.
• Supports family caregivers through health education and skills-training to ensure the Participant’s care needs are met in a safe and timely manner.
• Collaborates with the Center Manager, Home Care Supervisor, and other IDT members to ensure the seamless and successful delivery of community-based services, both at onset and on an ongoing basis.
• Remains up to-date on home care standards and best practices.
• Provides effective leadership by coordinating and integrating services within the department, with other departments and with the IDT’s primary functions.
• Provides care to participants in-person, via telehealth, and/or via telephone, as indicated.
• May provide after-hours on-call coverage as needed to support PACE participants when the PACE Center is closed
• Performs other job duties as required by manager/supervisor.
• Graduate of an accredited school of Nursing.
• Current unrestricted California RN license
• At least two years’ nursing experience, preferably in community-based or home health nursing.
• At least one year of experience working with a frail and/or older adult population.
• Valid driver’s license with good driving record within the past 5 years.
• Current documentation of Basic Life Support certification required.
• Bachelor’s degree or higher in Nursing (BSN/MSN)
• Certificate in Public Health Nursing (PHN)
• Experience conducting home visits.
• Additional training and/or certification in geriatrics.
• Must be able to fluently speak, read and write English.
• Fluency in Chinese (Cantonese and/or Mandarin) is required.
• Fluency in other languages is an asset.