Registered Nurse, Care Manager-PACE

Socket.dev; Riverside (CA); On-site; USD 90,000 - 115,000; Full time

Job summary

Neighborhood Healthcare PACE is seeking a Registered Nurse Care Manager to deliver comprehensive care coordination for seniors in Riverside County. The role entails patient assessments, coordinating care plans with the interdisciplinary team, and providing nursing services onsite at the PACE clinic.

The RN will support hospital discharge transitions, supervise home-based care, and educate participants and families on medications and safety, ensuring high-quality, patient-centered care.

Qualifications

• RN license in good standing.
• Experience in care coordination for PACE or similar programs.
• Ability to conduct home visits and comprehensive assessments.
• Strong documentation and compliance with regulations.

Responsibilities

• Conduct initial assessments and home visits to evaluate environment and needs.
• Coordinate semiannual assessments with IDT and participants' homes as needed.
• Document activities with participants, families, and providers per PACE policies.
• Implement and monitor care plans and nursing orders.
• Provide RN clinical coverage in the PACE clinic and triage when needed.
• Educate participants and families on nursing care and home medication administration.
• Collaborate with IDT to develop and adjust plans of care.
• Monitor participant outcomes and maintain safety and well-being.

Skills

RN (Registered Nurse)

Care coordination

Documentation

Patient education

Home visits

Emergency/triage

Interdisciplinary teamwork

Education

Registered Nurse (RN) license

Job description

About Us

Community health is about more than just vaccines and checkups. It's about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We're with you every step of the way, with the care you need for each of life's chapters. At Neighborhood, we are Better Together.

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.

As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 100,000 people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants.

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