ROLE OVERVIEW and PURPOSE

The Registered Nurse Care Manager will establish a well-rounded care practice by incorporating patient assessment, implementing/coordinating care plans, and monitoring routine evaluations to ensure medically appropriate care. This role will facilitate Interdisciplinary Team (IDT) care coordination and intensive medical management for participants discharged from hospitals/skilled nursing facilities, and the implementation of skilled nursing services. Additionally, this position will work with the IDT Social Worker and Physician to collect necessary medical and social information to support comprehensive decisions that ensure participants' safety and well-being.

Schedule: Monday-Friday, 8am-5pm. This position is onsite.

Responsibilities

• Manages the initial assessment for potential PACE participants, including home visits to support environmental and physical assessments
• Coordinates and completes semiannual assessments with 1:1 at PACE Multipurpose Center and/or at participant's home for assigned case load
• Documents activities encountered between participants, families, caregivers, contracted providers, hospitals, skilled nursing facilities (SNF), and other facilities working together to ensure the well-being of PACE participants in accordance with PACE policies, procedures, and regulatory requirements by providers
• Ensures implementation and compliance of participants care as ordered by providers
• Responds and manages medical emergencies based on necessary courses of actions dependent on the type of medical emergencies
• Provides RN clinical coverage in the PACE clinic
• Screens and triages participants, as needed
• Documents nursing care on the day service is rendered in accordance to established guidelines related to medical care provision
• Administers medications and treatments ordered by the physician/APP, including monitoring participant responses
• Participates on the Interdisciplinary Team to assess the nursing needs for participants
• Works with members of the interdisciplinary team (IDT), participants, and families in developing the plans of care for participants
• Maximizes participant functional capacity by encouraging autonomy in all aspects of care
• Educates, supervises, and counsels participants and/or caregivers regarding nursing care needs and other related problems
• Educates participants and families in safe administration of medication for home use, including assessing and encouraging compliance with medication regimen
• Initiates preventative and rehabilitative procedures or programs as appropriate for care and safety to participants
• Notifies appropriate medical personnel and IDT of changes in participant statuses
• Recognizes and understands the significance of abnormal test results to assist in gathering data, planning, and implementing care
• Provides safe total patient care to participants with complex health problems with a focus on individual participants and their families
• Maintains standards of nursing practice and follows hospital policies/procedures for care delivery and medication administration
• Evaluates participant outcomes and or progress toward achieving the objectives/goals of the care plan and communicates this information to IDT members
• Collaborates with IDT to revise the plan of care based on changes in participant physical or psychosocial status and initiates actions that are consistent with the changes in status
• Works with participants, families, and IDT members to evaluate/measure the individual and group response to nursing care and teaching interventions, including documenting the outcomes of the problems identified at scheduled reviews
• Maintains accurate and timely records of participant's functional health status, progress toward care plan outcomes, revisions to care plans, care given, etc.
• Advocates on behalf of participants and demonstrates accountability in resolving participant concerns or issues
• Complies and promotes the participant bill of rights, including assessing and working towards achieving high levels of participant satisfaction
• Keeps abreast of all regulations and standards to ensure compliance with orders or directives issued by duly constituted government/regulatory agencies
• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings, and workshops
• Attends meetings and participates on committees, as directed

Qualifications

Education/Experience

• Associate's degree in nursing required; Bachelor's degree in nursing preferred
• Valid CA RN license required
• Current Basic Life Support (BLS) certification through an American Heart Association (AHA)-approved source is required upon hire and must be maintained as a condition of employment
  
  • AHA-approved courses include an in-person, hands-on skills check with a certified instructor using a mannequin to demonstrate CPR and emergency response techniques
  • Online-only BLS courses without a live skills check do not meet this requirement
  • In addition, current CPR and First Aid certification are required for all PACE employees in accordance with CMS and DHCS requirements. First Aid training will be provided at onboarding and must be renewed annually.
• 1 year of nursing (clinical, outpatient, or general medicine) experience required; home or community health experience preferred
• Valid driver's license required and maintained as a condition of employment
• Active auto insurance required and maintained as a condition of employment
• Bilingual (English/Spanish) highly preferred

Additional Qualifications(Knowledge, Skills and Abilities)

• Excellent verbal and written communication skills, including superior composition, typing and proofreading skills
• Ability to interpret a variety of instructions in written, oral, diagram, or schedule form
• Ability to maintains acceptable standards of nursing care based on regulatory requirements
• Knowledgeable about and experience with adult day health center or PACE programs
• Ability to successfully manage multiple tasks simultaneously
• Excellent planning and organizational ability
• Ability to work as part of a team as well as independently
• Ability to work with highly confidential information in a professional and ethical manner

Physical Requirements

• Ability to lift/carry 50 lbs/weight
• Ability to stand for long periods of time

COMPLIANCE (Safety & HIPAA)

• Follow all safety procedures as outlined in Neighborhood Healthcare's Illness and Injury Prevention Plan (IIPP) and report any injuries and/or unsafe conditions immediately
• Maintain current knowledge of policies and procedures as they relate to safe work practices
• Use appropriate body mechanics to ensure an injury free environment
• Be familiar with location of nearest fire extinguisher and emergency exits
• Follow all infection control procedures including blood-borne pathogen protocols
• Maintain privacy of all patient, employee and volunteer information and access such information only on a need-to-know basis for business purposes
• Comply with all regulations regarding corporate integrity and security obligations
• Report all behavior and/or activity that are unethical, fraudulent, or unlawful

Neighborhood Healthcare offers a generous benefit plan that includes: Partially company paid Medical, Dental, and Vision Plans. Two plus weeks of vacation, Nine Holidays including two Floating Holidays of your choosing, Sick/Personal time, Volunteer Time Off (VTO), 403b Retirement plan (similar to a 401k), optional Health and Wellness events, and much more!

Pay range: $50.09 - $75.09 per hour, depending on experience. This role is eligible for a $2,500 signing bonus.

Compensation Disclosure: The posted salary range reflects the designated pay grade for this position. While this range represents the broader classification of the role, actual compensation will be based on several factors, including but not limited to the candidate's overall knowledge, skills, and experience, market data and industry benchmarks, internal equity within the organization, Budgetary considerations and organizational needs. As a result, placement within the range is not guaranteed, and the full pay grade range may not be utilized.