PACE Care Coordinator RN (Central Valley PACE - Modesto)

Under the supervision of the Medical Director and Clinical Supervisor , provides clinic nursing services including assessing participants, participates in the interdisciplinary team and care planning, implements care and case management, evaluates participant care and medical records, and provides clinical leadership to the assigned clinical care team.

Schedule: Monday – Friday, working 8:00am – 5:00pm.

Department: Clinic 

Compensation: $49.92 - $57.79 an hour

Employee Benefits:

• Health, Dental, and Vision Insurance
• Life, Accidental Death & Dismemberment (AD&D), and Long Term Disability (LTD) Insurance
• Retirement Savings: 403(b) plan with an employer match, Roth 403(b) option, plus a 401(a) retirement benefit after one year of service.
• Flexible Savings Account
• Work/life balance: 13 days of vacation, 11 days honored as Paid Holiday Off – 2 are half days (New Years Day and Christmas Eve Day). 

Duties and Responsibilities

• Demonstrates effective communication and problem solving skills.
• Supports the mission, vision, values and strategy of Golden Valley Health Centers by providing excellent participant-centered treatment, care, and services.
• Assessment of participants by utilizing critical thinking and advanced nursing skills.
• Refer - externally and internally, follow-up, interpret and record diagnostic results.
• Participates as a member of the Interdisciplinary care team (IDT), identify overt problems/needs, set priorities, and communicates participant changes.
• In coordination with the IDT, participant, family and caregiver, assists with the care planning process and evaluate participant care measures.
• Records observations related to impending or associated problems; implements nursing measures as appropriate.
• Provides care conforming to accepted practice standards, as prescribed, including treatments and procedures.
• Identifies emergency situations and independently initiates advanced therapy.
• Run daily reports of the participant panel for coordination of Tx/PX and utilization of internal and external care services.
• Collaborate internally regarding shared participant panels and utilization.
• Provide interventions that expand the level of services provided in association with the physician’s provisions of services and management of the participant’s care.
• Provide or coordinate procedures and tests, which are coded through separate non-E&M HCPCS codes. Review physician’s progress note to ensure all recommendations have matching orders in the EMR. 
• Track no shows, and work with the care coordination team and IDT as appropriate.
• Coordinate the admission of participants to PACE contracted hospital.
• Coordinate with the Utilization Management (UM) team for participant discharges from hospitals or skilled nursing facilities.
• Collaborate with the quality and UM team on quality measures and reports.
• Track outside medical appointments, radiology orders and lab orders ensuring follow up occurs in accordance with policy standards.
• Document assessment, procedures performed, participant education, evaluation, visit, intervention, participant response and treatment plan followed.
• Document any communication with the physician at the time of visit.
• Responsible for the clinical supervision of the care team, including mentoring and delegation to appropriate personnel, e.g., LVN and PCAs as appropriate in coordination with Tx/Px.
• Participates in QI process, comply with policies and procedures regarding safe working practices.
• Maintain, administer and reconcile medication.
• 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 participants 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 participants.
• 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

Minimum Qualifications

• 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.
• Knowledge of health characteristics affecting the frail or elderly population.
• Knowledge of participant rights and established mechanisms for management of ethical issues in participant care.
• 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.

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.
• One (1) year of experience in a home health agency, primary care clinic, or health facility as a registered nurse or license vocational nurse; or minimum five (5) years as a CNA or MA
• Minimum one (1) year experience working with the frail or elderly population.