Job Description

Introduction IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative programs transform lives, enhance communities, and save healthcare systems millions of dollars. We provide multiple ways to aid seniors in maintaining health, well-being, independence, and community participation. Responsibilities Conduct comprehensive nursing health assessments of participants’ medical needs, diagnose functional and cognitive abilities, and environmental and social needs to determine required services. Document assessment, case notes, care coordination, and utilization management. Collaborate with participants, their legal representatives, circles of support, and the PACE Interdisciplinary Team. Develop goals aligned with participants’ preferences, assessed needs, and circumstances. Create a plan of treatment (POT) specific to the assessed needs to mitigate risk and minimize service disruptions. Identify when services in the POT are available through friends, family, or publicly funded programs. Implement the POT, including identifying service providers and community resources to ensure timely, effective, and efficient mobilization of care. Provide cross‑training to other RNs as needed. Offer information, education, counseling, and advocacy on behalf of participants. Establish a care coordination schedule based on participants’ needs and acuity from initial assessment and subsequent reassessments. Monitor service delivery to ensure participants receive authorized care per their POTs. Maintain ongoing contact with participants and conduct at least a monthly face‑to‑face visit or telephone call to monitor health, mood, social integration, function, and overall well‑being. Conduct annual face‑to‑face visits, reassessments, and care plan updates. Follow up with participants after emergency department or inpatient admissions and collaborate with the IDT on safe discharge. Act as liaison nurse between facilities and the PACE IDT. Perform skilled nursing interventions as ordered by primary care provider and complete required documentation. Required Qualifications Current, unrestricted RN license in California. Current Basic Life Support (BLS) certification. Ability to pass a criminal background check and Live Scan. Experience establishing short‑ and long‑term goals for patient care that contribute to a continuum of care focus and result in quality patient care. Experience with medical diagnoses and medication for functionally impaired adults and older adults. Exceptional communication and presentation skills relating to functionally impaired adults and older adults, their support systems, and teams of health professionals. Demonstrated case management experience and skills within the community health care delivery system. Excellent detail orientation and problem‑solving skills. Demonstrated ability to prioritize multiple critical tasks. Excellent computer literacy. Additional Qualifications Minimum one year of experience in the previous three years working as a Nurse Case Manager for a licensed and certified home health agency or hospice agency, OR Minimum three years of experience in the previous five years in an area not listed above, such as a skilled nursing facility. Compensation Range: $110,000 – $130,000 per year. This range does not include any additional equity, benefits, or other non‑monetary compensation that may be included. Beware of Hiring Scams We are aware that third parties have reposted our job listings in an attempt to scam applicants. Please apply only through our official channels. Institute on Aging will never request payment or sensitive personal information such as Social Security numbers during the hiring process. All official communication will come from a verified IOA email address. If you receive any suspicious communication or requests, report them to talentacquisition@ioaging.org. All legitimate job openings can be found on the Institute on Aging Careers page. Equal Opportunity Employer Institute on Aging is an Equal Opportunity Employer. Institute on Aging is committed to cultivating a diverse and inclusive work environment and providing equal opportunities to all employees and job applicants without regard to age, race, religion, color, national origin, sex, sexual orientation, gender identity, genetic disposition, neuro‑diversity, disability, veteran status or any other protected category under federal, state and local law. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. #J-18808-Ljbffr Institute on Aging

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