PACE Level of Care Clinic RN (Central Valley PACE - Stockton)

Job Title

Under the clinical supervision of the PACE Center Manager RN, conducts level of care (LOC) assessments to determine participant eligibility, provides clinic nursing services including assessing patients, participating in the interdisciplinary team and care planning, implementing care and care management, evaluating patient care and medical records, and demonstrating leadership abilities.

Until our Stockton location is operational, the role will be based and trained at our Modesto center.

Schedule is Monday - Friday, 8:00am - 5:00pm.

Compensation: $49.92 - $57.79 an hour

Duties and Responsibilities

Clinical Responsibilities

• Demonstrates effective communication and problem solving skills.
• Supports the mission, vision, values and strategy of Golden Valley Health Centers by providing excellent patient-centered treatment, care, and services.
• Serve as the liaison for California Department of Health Care Services (DHCS) LOC assessments.
• Conduct full medical and environmental in-home assessments on prospective enrollees.
• Complete level of care documentation and submits for the state (DHCS) review initially and as required annually.
• Prepare and oversee the semi-annual level of care on-site audit in coordination with other interdisciplinary team members.
• Present prospective enrollee cases to the Interdisciplinary team as needed.
• In coordination with the interdisciplinary team, develop a plan of care based on nursing process that incorporates immediate and continuing care needs and includes the participant and family perspective.
• Educate the participant, family members and/or caregiver regarding the disease process, self-care techniques, and prevention strategies.
• Provide community resources and referrals as necessary prior to enrollment.
• Identifies emergency situations and takes appropriate action, including coordinating emergency services from home as appropriate.
• Assist Interdisciplinary team with forming a plan of care based on nursing evaluation.
• Assessment: Identifies patient's overt problems/needs and sets priorities; identifies problems requiring further referral and follow-up; interprets and records latest diagnostic results; performs advanced nursing assessments using critical thinking skills; collects data and completes required forms with appropriate responses according to clinic standards.
• Interdisciplinary care team (IDT) & Care Planning: Participates as a member of the IDT; assists with the care planning process in ordination with the IDT; includes the participant/family/care giver in process; makes referrals to interdisciplinary support services; participates in IDT initial and semiannual assessments; communicates participant changes to IDT.
• Implementing & Managing Care: Provide care conforming to accepted practice standards; provides correct treatments/procedures as prescribed; demonstrates age related characteristics and needs of Participants; provides participant health education; participates in twenty four (24) hour care; identifies emergency situations and independently initiates advanced therapy; acts as coordinator of patient care with other health care personnel and evaluates patient care measures; understands and respects patient rights and utilizes established mechanisms for management of ethical issues in patient care.
• Evaluation: Records patient care delivered as planned and any variation; makes and records observations related to impending or associated problems; implements nursing measures related to impending or associated problems.
• Leadership: Delegates nursing care to appropriate personnel; recognizes clinic problems and documents same; demonstrates participation in QI processes; complies with policies regarding safe working practices; recognizes inappropriate or inefficient patient care management; resolves issues/problems and completes written reports; fulfills call for clinic as assigned and adjusts work flows for census and acuity.
• Ability to interact professionally and respectfully with geriatric individuals including those with cognitive decline and/or physical frailties.
• Observes each participant for any change in physical, mental, emotional and social functioning and shall report such changes to the Interdisciplinary Team.
• Other projects and duties as assigned.

Physical Demands

Physical Requirements:

• Ability to lift up to 30 pounds. Moving, lifting or transferring patients may involve lifting or pushing greater than 30 pounds, should be done with assistance as appropriate.
• Ability to exert maximum muscle force to lift, push, pull or carry patients.
• Must be able to hear staff/clients on the phone and those who are served in-person, and speak clearly in order to communicate information to clients and staff.
• Must have vision with or without lenses that is adequate to read memos, a computer screen, personnel forms and clinical and administrative documents.
• Must have high manual dexterity.
• Must be able to reach above the shoulder level to work, must be able to bend, squat and sit, stand, stoop, crouching, reaching, kneeling, twisting/turning, fingering and feeling.

Work Environment

• Exposure to biohazards, including infectious material and waste and any other conditions common in a health care environment.
• Subject to unpleasant odors.
• The noise level in the work environment is usually quiet to moderate, but may at times be noisy and crowded.

Education/Experience Requirements

• Valid CA Driver's License, acceptable driving record, and vehicle insurance.
• Ability to lead and supervise effectively.
• Ability to work under stressful conditions.
• Creative, detailed-oriented and organized.
• Excellent written and verbal communication skills with specific ability to maintain accurate records.
• Ability to facilitate effective meetings.
• Excellent customer service skills.
• Must have integrity, practice discretion and practice objective problem solving.
• Data collection skills and knowledge of basic statistical principles.
• Skilled in establishing and maintaining effective working relationships with participants, coworkers, medical staff, and the public.
• Skilled in identifying and recommending problem resolution.
• Knowledge of safety and infection control requirements for healthcare facilities.
• Demonstrated experience in quality assurance and performance improvement activities and in the development and implementation of staff education with application of adult learning concepts.
• Proficient in Microsoft Office applications; advanced Microsoft Excel experience required.
• Maintains professional affiliations and any required certifications.
• Comfort with completing assessments routinely in the participant's residence.
• Successfully complete level of care training from DHCS within three months of hire in the position.

Education/Experience

• High school diploma or equivalent.
• Graduate of an accredited school of professional registered nursing.
• Current unencumbered CA Registered Nurse (RN) License.
• Current BLS CPR Card certified by American Heart Association.
• Minimum one (1) year as a Registered Nurse, preferably in either home or community health.
• Minimum one (1) year experience working with the frail or elderly population.

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.