Description The Clinic Registered Nurse at High Desert PACE serves as a cornerstone of the Interdisciplinary Team (IDT), providing skilled nursing care and coordination for seniors who wish to remain living independently in the community. This role is far more than traditional clinical nursing; it is a holistic, patient-centered position that balances acute triage, chronic disease management, and preventative advocacy for a vulnerable geriatric population.
Reporting directly to the Director of Nursing, you will act as a clinical lead within the PACE center, ensuring that participants receive high-quality care that aligns with their individualized care plans. You are the "eyes and ears" of the clinic, often serving as the first point of contact for participants experiencing changes in their health status.
Requirements
Clinical Excellence & Care Coordination Direct Care: Provide skilled nursing care and prescribed treatments to participants both in the Adult Day Health Center and within their private residences as directed and when applicable.
Assessment
- Conduct comprehensive nursing admission assessments and utilize the nursing process to identify care needs and develop specific, individualized plans of care.
- Execution of
- Orders: Ensure the physician’s plan of care is executed precisely, ensuring all tests, procedures, consultations, and diagnostics are completed timely.
- Hospital
- Liaison: Communicate effectively with hospital departments to minimize lengths of stay and facilitate smooth transitions back to alternative levels of care.
- Triage &
- Reporting: Identify and communicate barriers to the Physician’s plan of care directly to the PACE Primary Care Provider or Clinic Manager.
- Collaboration &
- Communication
- IDT
- Participation: Actively participate in Interdisciplinary Team Meetings, ensuring all nursing assessments and documentation are completed prior to the session.
- Family
- Advocacy: Maintain effective communication with clients and families regarding home care needs, coverage concerns, or health problems.
- Quality
- Improvement: Participate in quality management activities, including peer reviews, and advise leadership on ways to improve accountability to participants.
Operations
Manage the technical and organizational aspects of home care, including scheduling, communication.
Compliance
- Maintain continuity of service delivery while adhering to all governing regulations, agency policies, and the philosophy of High Desert PACE.
- Position
- Requirements &
- Basics
- Availability: Must be able to participate in a mandatory on-call rotation and provide temporary coverage for other sites as assigned.
Education
Graduate of an accredited School of Nursing.
Licensure
Current, unencumbered State Registered Nurse (RN) license.
Experience
Required: Minimum of one (1) year of experience working with a frail or elderly population (CMS requirement).
Setting
- This is an onsite/community-based position requiring travel to participant homes and presence at the PACE Clinic.
- Core
- Competencies
- Interpersonal
- Skills: Ability to navigate complex family dynamics and multi-disciplinary professional environments.
- Organizational
- Mastery: High aptitude for managing schedules, documentation, and regulatory compliance without sacrificing care quality.
- Clinical
- Judgment: Deep understanding of the nursing process as it applies to geriatric health and home safety. Education & Training RN with current license to practice as a professional nurse in the state of California. Bachelor of Science in Nursing, required. Minimum of total of one year of personal, clinical/leadership, and/or employment experience providing care or services for a frail or elderly population required. Experience in a home health agency, community-based or long-term care setting involving the elderly preferred. Two years of community nursing preferred. Proficient in computer operations acquired either through work experience or education, including word processing and spreadsheet programs. Ability to understand and prepare moderately complex written materials. Excellent verbal and written communication skills. Ability to work without close supervision and to exercise independent judgment. Ability to organize multiple tasks and projects and maintain control of workflow. Skills & Abilities Knowledge of physical, mental and social needs of frail older adults. Effective skills in physical assessment and chronic disease management for frail older adults. Effective listening and oral and written communication skills. Demonstrated ability to work effectively within the interdisciplinary team setting. Computer proficiency. Able to manage changing priorities per participant needs. Strong organizational skills. Demonstrates necessary skills and knowledge as outlined in the position-specific Competency Assessment Profile. Working Conditions The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Must be able to work required schedule. Requires physical strength to perform essential functions of the job. Occasional travel between sites, nursing/group homes and to members’ homes required. Requires use of personal vehicle. Requires valid driver’s license. Requires proof of automobile insurance coverage at the following minimum amounts in order to be reimbursed for mileage. May require use of personal cell phone for business purposes (may be eligible for stipend)
