Job summary:The Clinical Care Coordinator serves as the primary nurse care coordinator for an assigned panel of PACE participants. This role is responsible for comprehensive nursing assessments, care planning and effectuation, coordination across settings-including the PACE center, participant homes, contracted providers, hospitals, and skilled nursing facilities-and proactive management of chronic conditions to support participant safety, independence, and quality of life.
Essential Job Functions- IDT participation and care planning
- Conduct initial, semiannual, annual, and change-of-condition nursing assessments and update participant records in accordance with PACE requirements.
- Present assessment findings to the interdisciplinary team (IDT) and collaborate in developing and updating individualized plans of care with measurable goals and interventions.
- Ensure assigned care plan interventions are implemented, documented, and tracked; follow up with IDT members and external providers to resolve barriers and gaps.
- Longitudinal care coordination
- Provide ongoing clinical coordination for an assigned participant panel, including routine monitoring, triage, and early identification of changes in condition.
- Coordinate preventive care, chronic disease management, health maintenance, and risk-factor reduction for conditions such as CHF, COPD, and diabetes.
- Provide participant and caregiver education related to self-management, medication adherence, symptom monitoring, and the plan of care.
- Maintain timely communication with participants, caregivers, providers, and IDT members regarding changes in needs, services, and follow-up.
- Transitions of care
- Coordinate care during transitions to and from hospitals, emergency departments, skilled nursing facilities, and participants' homes.
- Communicate with hospital and SNF case managers and treating teams to support safe discharge planning, timely post-discharge follow-up, and reconciliation of orders.
- Arrange post-acute services, durable medical equipment, and supplies as indicated by the plan of care.
- Direct nursing care and clinical interventions
- Provide direct nursing care within RN scope as needed, including wound care, injections, IV hydration or therapies per policy, specimen collection, and phlebotomy when applicable.
- Carry out and document nursing interventions and provider orders accurately and promptly in the EHR.
- Triage participant symptoms in person, by phone, and virtually as appropriate, and escalate concerns to the PCP, NP, Medical Director, or designated nursing leader.
- Respond to urgent participant needs and complex clinical situations in accordance with established protocols and escalation procedures.
- Medication-related coordination
- Support medication reconciliation, monitoring for adverse effects, and coordination with pharmacy staff and prescribers.
- Identify and communicate medication adherence issues and safety concerns to the IDT and providers.
- Documentation, compliance, and quality
- Maintain complete, accurate, and timely documentation consistent with PACE policies and regulatory requirements.
- Follow CMS, state administering agency, OSHA, CDC, infection prevention, and organizational requirements within the scope of the role.
- Participate in quality improvement, infection prevention, safety, and audit-readiness activities; report incidents and complete assigned follow-up actions.
- Complete required education, training, licensure, certification, and competency requirements.
- Teamwork and participant-centered service
- Collaborate respectfully with participants, caregivers, colleagues, and external partners to provide coordinated, culturally responsive care.
- Participate in required IDT meetings, trainings, and nursing on-call or after-hours coverage as assigned.
- Contribute to a welcoming center environment and support effective clinical workflows without staff-management or performance-evaluation duties.
Minimum Qualifications- Graduate of an accredited School of Nursing.
- Minimum 2 years of experience working with a frail or elderly population, or completion of documented PACE training before independent care, consistent with CMS requirements.
- Bilingual ability in Cantonese and/or Mandarin and experience providing culturally and linguistically appropriate services.
- Demonstrated ability to complete comprehensive assessments, perform clinical triage, coordinate care across settings, and collaborate effectively with interdisciplinary teams.
- Ability to document in an Electronic Health Record (EHR) and use standard office software.
- Ability to make home visits as assigned.
- Must meet PACE program competency requirements before working independently.
- Must be medically cleared for communicable diseases and maintain immunizations and vaccines in accordance with policy.
Certifications, Licenses, Registrations- Current Registered Nurse (RN) license in good standing in California, or ability to obtain as required.
- Current CPR/BLS certification, or ability to obtain within the required timeframe.
$120,366 - $135,366 a year
Benefits That Support YouWe're committed to supporting our team's well-being. Our comprehensive benefits package includes:
Health & Wellness- 100% employer-paid medical, dental & vision coverage
- Acupuncture & chiropractic coverage
Time Off- 12 vacation days
- 12 sick days
- 12 paid holidays + 3 floating holidays (additional flexible days you can use anytime)
Financial & Retirement- 403(b) with 3% employer contribution + up to 2% match
- Flexible Spending Account (FSA) & Dependent Care Assistance
Additional Support- Commuter benefits
- Long-Term Disability Insurance
Please note: We are not seeking support from staffing agencies at this time. Direct applicants only.
We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.
