PACE Home Care Coordinator RN

Under the direct supervision of the RN Home Care Manager, the PACE Home Care Coordinator (HCC) RN is responsible for the development and implementation of homecare services for program participants, including the coordination of all Durable Medical Equipment and provide RN coverage in the PACE Clinic.

Essential Functions of the Job :

Assesses, using the nursing process, the home care needs of a frail elderly population, and identifies and develops specific plans of care.

Initial and periodic assessments to be conducted minimally every 6 months and must be completed prior to the scheduled IDT team meeting.

Communicates participant changes with team members.

• Provides ongoing education and / or instructions to the patient, family and / or caregivers about goals and expectations, safety at home, use of equipment and other topics as indicated.
• Regularly completes home visits to assigned caseload to evaluate nursing needs and facilitate clinical services such as wound care, medication administration, lab drawings and collection, and other services as indicated upon evaluation.
• Coordination of 24-hour care delivery and the implementation of all home care services which include nursing, PT, OT, ST, and personal care services to ensure that quality services are provided to meet participant needs.

Monitors contracted personal care staff to ensure delivery of personal care services as outlined on plan of care.

• Coordinates and authorizes all Durable Medical Equipment. Creates and maintains inventory of all home care and durable medical supplies.
• In conjunction with Case Management, coordinates all home care and DME needs for participants according to program standards.

May include interaction with other facility staff.

• Resource management of in-home support staff in conjunction with RN Supervisor and Center Manager. Evaluates quality of home care services provided.
• Participates as a member of the Interdisciplinary Team. Attends staff meetings and takes part in participant care planning.

Communicates any changes in participant condition to team members.

• Communicates and interacts with patient caregivers and / or family members as needed. Takes on call rotations on an alternating basis to include weekends and evening.
• Provides RN clinical coverage in the PACE clinic as needed.

Additional Duties and Responsibilities :

• Follows established departmental and position specific policies and procedures and updates as needed.
• 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 as required and participates on committees as directed.
• Performs other duties as assigned.

Job Requirements :

Experience Preferred :

• 6-months RN experience with home health or community health
• EMR : Epic experience
• Geriatric experience

Education Preferred :

Bachelor of Science in Nursing

Certification Required :

• Current CA RN License.
• Valid CA driver license and reliable transportation.

Verbal and Written Skills Required to Perform the Job :

Excellent oral, written communication, and interpersonal skills.

Technical Knowledge and Skills Required to Perform the Job :

• Must be able to work effectively in a team environment.
• Must be able to treat geriatric patients.
• Only act within the scope of his or her authority to practice.
• Meet a standardized set of competencies established by San Diego PACE and approved by CMS before working independently .

Equipment Used :

• Personal Computer
• EMR : Epic

Working Conditions and Physical Requirements :

Physical clearance for reaching, bending, stooping, crouching, kneeling and grasping; have full range of motion; ability to lift 50 lbs.

need to lift and transfer participants.

• T.B. Clearance
• Must maintain current Basic Life Support (BLS)

Universal Requirements

Pre employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs.