Job Description
Job Description
IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the “status-quo” and create new and more innovative ways to help aging adults and adults with disabilities maintain their quality of life.
With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence and participation in the community, fulfilling our mission.
The Community Health Nurse will be responsible for conducting initial and routine comprehensive nursing assessments, coordinate care with Residential Care Facilities for the Elderly (RCFEs) and Skilled Nursing Facilities (SNFs) and provide simple nursing interventions as needed.
The RN will be an active participant with the PACE Interdisciplinary Team (IDT) and contribute to the creation and evolution of the patients’ care plan. This role will also collaborate with the IDT to ensure safe facility discharge.
Key duties and responsibilities include, but may not be limited to the following:
- The RN will conduct comprehensive nursing health assessments of participants’ medical needs, diagnose functional and cognitive abilities and environmental and social needs to determine which service(s) are required to meet participants’ needs and preferences in the community.
- Document assessment, case notes, care coordination, and utilization management.
- Work with the participants, their legal representatives, circles of support, and PACE interdisciplinary team.
- Develop goals associated with the participant’s preferences, assessed needs, and individual circumstances.
- Develop a plan of treatment (POT) specific to the assessed needs of the participant to mitigate risk and minimize disruptions in services.
- Identify when services identified in the POT are available through friends, family, and/or publicly funded programs.
- Implement the POT, which includes identifying service providers and community resources to help assure the timely, effective, and efficient mobilization and allocation of the services of care.
- Provide cross-training to other RNs as needed to support the needs of the participants.
- Providing information, education, counseling, and advocacy to, and on behalf of participants.
- Establish a care coordination schedule based on the needs and acuity of the participant as determined by their initial service needs assessment and subsequent reassessments
- Monitor the delivery of services to ensure participants are receiving care as authorized in their POTs.
- Monitor the quality of the authorized services by maintaining ongoing contact with participants. Degree of monitoring is based on the acuity of the patient, but a minimum of a monthly face-to-face visit or telephone call to monitor for changes in health, mood, social integration, functionality, and overall wellbeing is required.
- Conduct annual face-to-face visits, reassessments, and care plan updates
- Follow up with the participant after Emergency Department and in-patient facility admissions and collaborate with IDT on safe discharge.
- Act as the liaison nurse between facilities and PACE IDT.
- Perform skilled nursing interventions as ordered by PCP and complete documentation as required.
Required Qualifications - Current, unencumbered license to practice as an RN in the State of California
- Current Basic Life Support (BLS) certification
- Ability to pass a Criminal Background Check and Live Scan.
- Experience establishing short and long-range goals for patient care which contribute to a continuum of care focus, and patient care will be delivered in accordance with the professional nursing process, which resulted in the delivery of quality patient care.
- Experience with, and understanding of, the medical diagnoses and medication associated with 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
AND
- A minimum one year experience in the previous three years working as a Nurse Case Manager for a licensed and certified home health agency or hospice agency OR
- A minimum three years experience in the previous five years in an area not listed above, such as skilled nursing facility.
Compensation - Range: $ 110,000.00 -130,000.00/annual
- This amount is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any specific employee, which is always dependent on actual experience, education and other factors. This range does not include any additional equity, benefits, or other non-monetary compensation which may be included.
Beware of Hiring Scams We are aware that some third parties have reposted our job listings in an attempt to scam applicants. Please be cautious and only apply 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.
We encourage you to learn more about IOA by visiting us here. IOA reserves the right to adjust work hours or duties when appropriate. 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.
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