PACE RN Care Coordinator

Job Description

Job Description

Job Title : RN Coordinator

Supervisor : Center Manager

FLSA Status : Exempt

Salary Range : See Scale

Job Summary : Under the direct supervision of the Team Lead / Center Manager and indirect supervision of the Chief Operating Officer.

Responsible for the development and implementation of homecare services for program participants, including the coordination of all Durable Medical Equipment and nursing home care.

Specifications

Education : Graduate of an accredited school of nursing. (BSN Preferred)

Experience : Has practiced nursing in the last 3 years. Has 3 years RN experience with at least 1 year of experience working with the frail, elderly population.

Number and Type of Employees Supervised (optional) : None

Licensure, Registry or Certification Required : RN currently licensed in North Carolina. Valid NC driver's license and vehicle.

Special Training : Must possess knowledge and skills necessary to treat patients; other training as required by department.

Only act within the scope of his or her authority to practice. Meet a standardized set of competencies established by PACE of the Southern Piedmont and approved by CMS before working independently.

Immunizations : Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact

Ages of Patients Rendered Care :

Neonate / Infant Early Childhood Adolescent Adult Geriatric All Age Groups

Key Responsibilities :

Assessment and Documentation

• Collects participant data and completes required assessments according to regulatory standards.
• Identifies problems / needs and sets priorities.
• Identifies problems requiring further referral and / or follow-up.
• Records latest diagnostic results and communicates to appropriate provider.
• Performs advanced nursing assessment using critical thinking skills.
• Performs general nursing care on participants including administering prescribed medications and treatments.
• Assists provider in the examination, assessment, evaluation testing and treatment of participants, as needed.
• Provides training in self-administration of all non-scheduled medications and monitors medication compliance.

Plan of Care

• Develops a plan of care based on nursing process and which incorporates the plans of other disciplines and continuing care needs.
• Includes the participant / caregiver in developing or revising the plan of care.
• Initial and periodic assessments (minimally every 6 months) to be completed prior to the scheduled team meeting.
• Develops, implements, and maintains a current nursing plan in cooperation with the providers.
• Participates within the Interdisciplinary Team in the formulation of Plans of Care for program participants, as well as in other Interdisciplinary Team settings, as necessary, that plan, coordinate and monitor the care of program participants.
• Effectively communicates in Interdisciplinary Team meetings, caregiver meetings, and clinic meetings.

Care Management

• Care provided conforms to accepted practice standards.
• Provides correct treatments / procedures and other care as prescribed and according to patient care standards.
• Demonstrates understanding of age-related characteristics and needs of patients served.
• Provides health education to participants and their caregiver(s) on an individual or group basis.
• Instructs participants and caregiver(s) regarding medications and treatment instructions.
• Identifies emergency situations and independently initiates appropriate treatment within nursing scope of practice.
• Coordinates participant care with other health care personnel and evaluates patient care measures instituted.
• Understands and demonstrates respect for patient rights and utilizes established mechanisms for management of ethical issues in patient care.
• Coordinates services both in and out of the PACE Center (includes contracted medical services follow-up).
• Identifies emerging needs as high risk and coordinates care accordingly to improve outcomes.
• Care delivery is efficient right care, at the right place, at the right time in the right amount.

Evaluation

• Documents all necessary information and maintains participant medical record(s) and fulfills organization’s charting and reporting requirements.
• Observes, records and reports participant condition and reaction to drug and treatments to providers.
• Implements nursing measures related to impending or associated problems and updates and / or revises Plan of Care accordingly.

Leadership and Communication

• Using nursing process, delegates nursing care to appropriate personnel.
• Integrates cost effective measures into nursing practice.
• Demonstrates active participation in QI processes.
• Complies with policies addressing safe working conditions.
• Monitors unsafe working conditions and reports accordingly.
• Recognizes inappropriate and / or ineffective patient care management and reports to Medical Director.
• Resolve issues / problems and completes written reports (i.e., incident reports, on-call log, grievances report, service request, etc.)
• Assesses clinic in addition to evaluating the overall effectiveness of the clinic in the absence of the Clinical Services Manager.
• Other duties as assigned by supervisor.

Participant Interface : Must be comfortable and eager to engage our participants in a warm and welcoming manner while maintaining a professional distance and attitude.

Experience with issues of aging and health challenges would be helpful. Demonstrates knowledge of and supports PACE mission, vision, values, standards, policies and procedures, operating instructions, confidentiality standards, and the code of ethical behavior.