• Job Description

  Req#: 503851

  Under the direct supervision of the Center Manager, the PACE Community Services Nurse is responsible for assessing medical level-of-care eligibility for prospective PACE enrollees, and for assessing and implementing a plan for community-based caregiving services. He/she is one of the first introductions for prospective PACE enrollees to the PACE Interdisciplinary Team (IDT) and works in partnership with the Enrollment Specialist to ensure a smooth and successful transition into the PACE program.

  
  

  ESSENTIAL JOB FUNCTIONS:

  • Completes level-of-care documentation and submits for review to the Department of Health Care Services (DHCS), initially for prospective PACE enrollees and as required annually for enrolled Participants.
  • Presents prospective enrollee cases to the Interdisciplinary Team (IDT), as needed.
  • Participates as an active member of the IDT for Participant care planning.
  • Conducts comprehensive nursing assessments, reassessments, and in-home evaluations on prospective or enrolled PACE participants developing and documenting care plan services and/or enrollment recommendations.
  • Coordinates with the IDT to develop an individualized in-home Care Plan.
  • Collaborates with the Home Care Supervisor to oversee the implementation and continuation of care plan services in the participant’s home.
  • Ensures all participant changes are documented appropriately in the medical record and communicates participant changes to IDT in a timely manner.
  • Assists with identifying qualifications and competency requirements for caregiving staff, and in providing training and competency checks.
  • Supports family caregivers through health education and skills-training to ensure the Participant’s care needs are met in a safe and timely manner.
  • Collaborates with the Center Manager, Home Care Supervisor, and other IDT members to ensure the seamless and successful delivery of community-based services, both at onset and on an ongoing basis.
  • Remains up to-date on home care standards and best practices.
  • Provides effective leadership by coordinating and integrating services within the department, with other departments and with the IDT’s primary functions.
  • Provides care to participants in-person, via telehealth, and/or via telephone, as indicated.
  • Provide home health as needed.
  • Utilize Epic appropriately and efficiently and serve as content and workflow expert for resolving issues and proposing solutions in Epic
  • Performs other job duties as required by manager/supervisor.
  • May provide after-hours on-call coverage to support PACE participants when the PACE Center is closed as needed.

  QUALIFICATIONS:

  Required:

  • Valid unrestricted California RN license.
  • Graduate of an accredited school of Nursing.
  • Current BLS and First Aid required

  Preferred:

  • Bachelor’s degree or higher in Nursing (BSN/MSN)
  • Certificate in Public Health Nursing (PHN)
  • At least two years’ nursing experience, preferably in community-based or home health nursing.
  • Valid driver’s license with good driving record within the past 5 years.
  • Experience in conducting home visits
  • Additional training and/or certification in geriatrics.
  • At least one year of experience working with a frail and/or older adult population.
    
    

  LANGUAGE:

  • Must be able to fluently speak, read and write English.
  • Fluency in Chinese (Cantonese) is required.
  • Fluency in other languages is an asset.

  
  

  STATUS:

  This is an FLSA non-exempt position.
  This is not an OSHA high-risk position.
  
  

  NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

  NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).

• About the company

  North East Medical Services (NEMS) is a non-profit community health center serving the medically-underserved populations of the San Francisco Bay Area.

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