Registered Nurse, PACE

Description Esperanza Health Centers offers benefits to all its full-time employees: BCBS Medical PPO Plans | Ameritas Dental | Eye Med Vision | 401K | Tuition Reimbursement up to $5,000 per year |10 Paid Holidays and 21 Days of Paid Time Off

Schedule

Full-Time, Monday through Friday shift with rotating on-call coverage for evenings and weekends.

Compensation (Based on experience and qualifications)

$70,200.00 - $87,000.00

• What is PACE?
• PACE, or Program of All-Inclusive Care for the Elderly, is an alternative care model for those over 55 years of age requiring nursing home level of care which aims to keep participants living at home in the community.
• PACE is a collaborative, interdisciplinary approach which coordinates all levels of medical and social needs, including prevention, wellness, socialization, primary care, and access to specialists and other services.
• The Registered Nurse (RN) supports and coordinates the clinical care needs of PACE participants through comprehensive nursing assessment, monitoring, care coordination, and communication of clinical concerns and recommendations to the PACE Interdisciplinary Team.
• Primary

Duties and Responsibilities

Perform and oversee nursing functions within the PACE program. Conduct initial nursing assessments, scheduled reassessments, and as-needed reassessments for PACE participants. Develop, implement, and update individualized participant care plans in collaboration with the Interdisciplinary Team (IDT). Monitor participant conditions and communicate changes in health status, clinical concerns, and recommendations to providers, IDT members, participants, and caregivers. Implement provider orders and coordinate services with internal departments, contracted providers, and community vendors. Participate in after-hours on-call rotation as assigned and collaborate with the Advanced Practice Registered Nurse (APRN) and/or PACE Physician to address urgent and emergent participant needs. Complete accurate and timely documentation within the electronic health record (EHR), including participant visits, telephone encounters, home visits, assessments, and care coordination activities. Review participant medical records to ensure laboratory results, specialist reports, diagnostic findings, and other clinical documentation are appropriately maintained and incorporated into the medical record. Participate in participant-related activities and meetings, including Interdisciplinary Team meetings, family conferences, grievances, Service Determination Requests (SDRs), appeals, and regulatory reviews. Provide clinical supervision, guidance, and oversight to Licensed Practical Nurses (LPNs) as assigned. Assist with onboarding, orientation, staff training, and ongoing clinical education initiatives. Support infection prevention and control efforts in collaboration with organizational leadership, the Medical Director, and the PACE Site Director. Collect participant data and complete required reports, assessments, and documentation in accordance with regulatory and organizational requirements. Participate in quality improvement, quality assurance, and compliance activities, including medical record audits and corrective action initiatives. Maintain readiness for federal, state, CMS, and organizational surveys and audits. Coordinate care and facilitate communication among participants, caregivers, hospitals, long-term care facilities, contracted providers, and community partners to ensure continuity of care.