Under the supervision of RN Manager, PACE Center, Responsible for the assessment of prospective PACE participants ability to safely live independently in the community with PACE services through using established evaluation tools to assess if the current living environment is safe and stable, and if the prospect meets eligibility criteria for PACE enrollment.

Job Roles

• Accompany Business Development Representative to initial home contact meeting. Evaluate for safety and stability of home environment and assess that prospective participant is appropriate for PACE using established criteria and guidelines.
• Determine if prospective participant is currently enrolled in any State funded programs that would preclude them from enrolling in PACE including but not limited to SD County in-home support service (IHSS) and DMH programs.
• Educate potential participant that they are not eligible to be submitted for PACE until they are disenrolled in any disqualifying state programs. Provide alternative resources if available.
• Present prospective participants to interdisciplinary team (IDT) for approval to move to Level of Care assessment.
• Provide individualized resources to any prospective participant that is not eligible for PACE.
• Provide education on criteria to be met that might qualify prospective participant to enroll in PACE. (Ex: disenroll in other state programs, move into a safe and stable home environment, move into an alternate living facility (ALF) or Board and Care facility if 24- hour supervision required.)
• Perform an in- home level of care assessment for prospective participants following established guidelines.
• Assess participant goals and wishes for participating in PACE program.
• Complete DHCS LOC form and Certification form and submit to RN Manager for review and submission to DHCS.
• Upon approval to participate in program, determine home health and home care needs in an hour of care format using data and observations from initial home assessment and LOC assessment. The individualized home care determination will be established through the home care service/hour tool and clinical judgement.
• Participate in pre-enrollment mini- assessment to review the home care needs assessment with potential participant including family or other support person(s).
• Review the participant goals and wishes and determine that they have not changed.
• Together with the potential participant and their family or support person(s), establish a home care plan of care. This is to be completed prior to the potential participant signing the enrollment form.
• After enrollment, collaborate with home care supervisor to review established home care plan of care to be implemented.
• In collaboration with RN manager, audit, and review home care services for compliance to care plan at a minimum of every 3 months. Plan of care should be regularly updated as participant meets goals or require new goals to be established.
• In collaboration with RN Manager, review outsourced home care services and home health services to ensure services are being delivered as ordered and discontinued when appropriate on a weekly basis.
• Audit home health charts for completion.
• Performs other duties as assigned.

Education/Certifications/Licenses/Registrations

• California State Board RN License required.
• Current American Heart Association healthcare provider CPR (BLS), or Advanced Cardiac Life Support, Advanced Trauma Life Support, or Advance Resuscitation Training.
• Graduation from a recognized RN/BSN program.
• High School Graduate (or GED equivalent).
• Ability and means to travel as needed in a timely manner within San Diego County, to locations that may have limited access to public transportation; proof of liability and property damage insurance on vehicle used is required. DRIVER REQUIREMENTS: Age 21; Licensed for a minimum of 3 years; No violations and/or accidents within 3 years; No vehicle related suspensions/reinstatements; No DUI, reckless or felony Driving within 7 years.

Experience/Specialized skills (including Language)

• 1 – 2 years of experience working with the older adult population.
• Clinical competency with the older adult population including physical and cognitive assessments preferred.
• Experience in Home Health Care preferred.
• Ability to work effectively in a team environment.
• Demonstrated ability to communicate effectively and openly with other interdisciplinary team members on participant status and needs.
• Must be able to multi-task, be flexible, ensure accuracy, and meet changing priorities in a fast-paced, high workload environment.
• Basic computer literacy to comply with department needs and expectations (i.e., E-HR documentation, obtaining background information and reports, following up on appointments, etc.).
• Bilingual English/Spanish preferred.

Job Type: Full-time

Benefits:

• 401(k) matching
• Dental insurance
• Disability insurance
• Health insurance
• Loan forgiveness
• Paid time off
• Tuition reimbursement
• Vision insurance

Physical setting:

• Clinic

Schedule:

• 8 hour shift
• Day shift

Ability to commute/relocate:

• San Diego, CA 92115: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Nursing: 1 year (Preferred)

License/Certification:

• BLS Certification (Preferred)
• RN (Preferred)

Work Location: One location

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