Registered Nurse, Care Manager-PACE; Riverside

Overview

Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community. We are a private, non-profit 501(C)(3) community health organization serving over 500k medical, dental, and behavioral health visits from more than 100,000 people annually, with two PACE centers located in Riverside County and capacity to serve over 650 senior participants.

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 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 ensure comprehensive decisions are made to ensure the safety and well-being of participants.

• 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/laws
• 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

• Associate's degree in nursing…