Job description

Job Summary

The RN Home Care Coordinator for the AgeWell PACE (Program of All-Inclusive Care for the Elderly) program, is responsible for the development and implementation of homecare services for program participants, including the coordination of all Durable Medical Equipment and nursing home care.

Position Responsibilities

Assesses, using the nursing process, the home care needs of a frail elderly population, and identifies and develops specific plans of care. Initial and periodic assessments to be conducted minimally every 6 months and must be completed prior to the scheduled team meeting. Communicates participant changes with team members.

Coordination of 24 hour care delivery and the implementation of all home care services which include nursing, PT, OT, ST and personal care services to ensure that quality services are provided to meet participant needs.

Coordinates and authorizes all Durable Medical Equipment.

Coordinates and supervises all nursing care for participants in the nursing home/boarding home according to program standards. Includes interaction with other facility staff.

Performs evaluations of HCT's. Human resource management of HCT staff in conjunction with Center Manager.

Participates as a member of the Interdisciplinary Team. Attends staff meetings and takes part in participant care planning. Communicates any changes in participant condition to team members.

Possess the Ability To

Maintain a positive, flexible, and solution-focused attitude, with both the ability to collaborate effectively in a team setting and to work independently.

Provide feedback to support IDT decision making.

Be organized within busy center and clinic environments.

Maintain effective interpersonal relationships cross-departmentally, and, as applicable, with agencies, members, providers, and the general public.

Communicate effectively, both verbally and in writing, with individuals from varying cultural backgrounds.

Prepare concise and clear reports.

Multi-task on projects and their respective activities, timelines, and issues.

Effectively utilize computer and software tools.

Only act within the scope of their authority to practice.

Work in a dynamic and fast-changing environment.

Work within an effective team environment, where each team member is held accountable for their independent work.

Approach the role with an openness to new ideas, cultural humility, and acknowledgment of the dynamics of privilege.

Reinforce strategic DEI initiatives set by the leadership team and Board of Directors and assist in building a culture that models inclusive behaviors, proactively manages bias, and provides opportunities for strengthening DEI acumen through development and training.

Meet a standardized set of competencies for the specific position description established by AgeWell PACE and approved by regulatory agencies before working independently.

Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.

Pass a criminal background

Knowledge of

Physical, mental, and social needs of frail older adults.

Principles and practices of health care, health care systems, and managed care.

Community-based organizations, agencies, and community services.

Culture and needs of the socially and ethnically diverse population AgeWell PACE serves.

Team and value-based care.

Regulatory policies, rules, and regulations.

Familiarity and/or experience with geriatrics.

Experience & Education

Bachelor of Science in Nursing

At least 1 year as an RN, preferably in either home or community health. Supervisory experience desired. At least 1 year experience working with the frail or elderly population.

Licensed RN in CA, current, valid CA driver's license and vehicle.

Must be able to work effectively in a team environment. Must be able to treat geriatric patients. Only act within the scope of his or her authority to practice. Meet a standardized set of competencies established by AgeWell PACE and approved by CMS before working independently.

Physical Demands and Work Environment

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical demands: Employee must be able to sit for extended periods of time. Employee will also be actively present throughout the PACE center, engaged with employees, participants and with staff. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Employee must be able to talk and hear, particularly for daily interactions with staff and elderly participants.

Work Environment: Employee must be able to work in a busy and demanding clinic environment with moderate to loud noise levels.

The Job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The Employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

Job Type: Full-time

Pay: $50.00 - $58.00 per hour

Benefits:

• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday
• Weekend availability

Ability to commute/relocate:

• Rohnert Park, CA 94928: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Nursing: 3 years (Preferred)
• Case management: 2 years (Preferred)

Work Location: One location

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