Registered Nurse Care Coordinator

The Program of All-Inclusive Care for the Elderly (PACE) offers a variety of services, with many of them provided onsite at a PACE Center.PACE is an alternative to nursing home care and – through an interdisciplinary care team (IDT) of physicians, nurse practitioners, nurses, social workers, therapists, van drivers, and aides – coordinates and provides preventive, primary, acute, and long-term care services, so older individuals can continue living in the community.Why You'll Love it Here:PurposeProfessional DevelopmentPaid HolidaysPTO and SIck TimeInternal opportunities for growthTeam SupportCompetitive PayMedical, Dental, Vision InsuranceLife insurance403(b) Retirement SavingsEmployee AssistanceAnd MORE!Primary PurposeThe Registered Nurse Care Coordinator (RNCC) works to coordinate, manage, and optimize patient-centered care by collaborating with participants, families, and the interdisciplinary team (IDT) to ensure timely, high‑quality, and cost‑effective care across the continuum, while promoting participant autonomy, education, and positive health outcomes. Is independent in the application of advanced nursing knowledge and skills and is able to manage complex clinical situations. May supervise both licensed and non-licensed personnel.Accountability Chart Key RolesCare plansIn-home AssessmentsChronic disease managementMedication managementTransitions of careParticipant advocacyDuties And ResponsibilitiesDevelop, implement, and update individualized care plans in collaboration with the Interdisciplinary Team, participants and families.Triaging participant needs, requests/concerns, and calls throughout the day.In home medication review, set up, and problem solving for increase adherence/usage.In home assessments, including obtaining initial medication list and educational needs related to participant health.Chronic disease education/management including creating action plans and hospital diversion plans to prevent exacerbation of an illness or hospitalization.Ordering supplies and evaluating continued need for oxygen equipment, incontinence supplies, Lifeline/PERS, and other chronic disease related equipment.Liaison with external vendors (Adult foster care, Skilled nursing facilities, hospital, provider offices, hospice).Assist with hospital discharge planning and transitions of care in collaboration with the Transition Navigator and Transition Resource Specialist.Complete sign-on and routine visits for participants enrolled in Senior Care Partners PACE End of Life Services. Providing education regarding the end-of-life changes and medications to caregivers/families.Participates in and facilitates meetings regarding care coordination with families/caregivers- including Advanced Care Planning conversations and family meetings.Assists with clinical tasks as needed such as skin assessments, immunizations, medication administration, focused nurse assessment for acute medical concerns, and lab collection (urinalysis, stool sample, nasopharyngeal swab, and blood sugars).Active participant in collaboration of care needs with the Interdisciplinary Team (IDT).Must complete all required education and file requirements on time.Documents in the participant’s medical record as required by policy.Must care, support, and collaborate with everyone involved in the participant’s care including staff and the participant’s family using the participant centered care model.Keeps the leader informed of problems or issues.Performs other duties as assigned.Supervisory ResponsibilitiesThis position has no professional supervisory responsibilities.QualificationsRN–Nursing Diploma or Degree from accredited School of Nursing or University.Minimum of one year of experience working with the frail, elderly, or long-term care population.Minimum of one year home care experience required.Additional RequirementsMust be fully vaccinated or willing to become vaccinated against: Influenza, MMR, Varicella, Tdap/Td, COVID-19, and Hepatitis BMust meet CMS competency standards prior to working independentlyMust be willing to work beyond normal hoursComfortable working in varied home environments and all-weather conditions Join Us!If you’re ready to do meaningful work in a place where you feel you truly belong, where partnership drives every interaction, and where excellence and ownership guide how we care for our participants and one another, we invite you to apply. Senior Care Partners PACE is proud to be an Equal Employment Opportunity employer.