PACE Home Care Coordinator (Registered Nurse)

Care Guide Partners PACE is a part of Hosparus Health.
As a Program of All-Inclusive Care for the Elderly (PACE) provider, we work to empower people 55 and older with the support they need to stay in the homes they know and love as they age.
PACE helps seniors who need nursing home-level care maintain their independence by providing all the medical care and support services they need to continue living comfortably and safely at home.
RN Position Summary: The PACE Home Care Coordinator (HCC) is responsible for the development and implementation of home care services for program participants, including the coordination of all Durable Medical Equipment (DME) and community-based care.
The HCC is responsible for assessing and identifying participant/family/caregiver needs and providing general and skilled nursing care to participants.
The HCC plans, evaluates, implements, and documents the individualized nursing care provided to a participant in accordance with the interdisciplinary plan of care and the policies and expectations of the PACE program according to regulatory standards.
The HCC is responsible for care coordination and collaboration among the Interdisciplinary Team as well as other medical providers, and oversees the care provided by Licensed Practical Nurses and Certified Nursing Assistants.
RN Position Duties & Responsibilities: • Provides excellent participant-centered treatment, care, and services in accordance with PACE policies, procedures, guidelines, and regulations.
Assesses the need for, and evaluates all care, treatment, and services.
• Performs initial assessments of participants in their home environment to determine their individual needs and coordinates plan of care with care-giving resources.
• Performs at least bi-annual re-assessments of participant to determine that appropriate in-home services are provided and that participants are in the least restrictive environment.
• Coordinates all Durable Medical Equipment (DME) and community-based care.
• Serves as a liaison between Care Guide Partners PACE and contracted Home Health Agencies and Personal Care Agencies.
• Controls and prioritizes utilization of homecare staffing needs to reflect actual enrollee homecare needs.
• Ensures all contracted Home Health Agency staff complete initial and annual competency testing.
• Participates as a member of the Interdisciplinary Team (IDT) by developing an initial and appropriate participant Plan of Care (POC).
• Reviews/revises the POC in coordination with the IDT and per regulatory requirements as participant status changes and as driven by needs identified as significant by the participant/family/caregiver.
• Participates in assessments and makes referrals to interdisciplinary support services as needed.
• Identifies participant issues/needs and sets priorities for addressing and following up as necessary, interprets and accurately records latest diagnostic results, performs advanced nursing assessments using critical thinking skills, collects data, and completes required forms with appropriate responses according to program standards.
• Provides care, including correct treatments and procedures, conforming to accepted PACE practice standards and as prescribed.
• Monitors medication compliance, administers medications, and provides training in self-administration of all non-scheduled meds as needed.
• Identifies emergency situations and independently initiates appropriate measures based on established policies and procedures.
• Acts as the coordinator of participant care with other health care personnel and evaluates participant care measures.
• Knowledgeable of participant rights and ensures an atmosphere that allows for the privacy, dignity, and well-being of all participants in a safe, secure environment; utilizes established mechanisms for management of ethical issues in participant care.
• Delegates nursing care to appropriate personnel including LPNs and CNAs.
• Observes each participant for changes in physical, mental, emotional, and social functioning and reports such changes to the IDT.
• Participates in center quality improvement activities.
• Evaluates participant complaints; assists participants and caregivers in filing grievances.
• Communicates clearly, concisely, and in a timely and positive manner with team members, community partners, referral sources, and participants/families/caregivers.
• Mediates and solves problems effectively.
• Identifies and provides for educational needs of the participant/family/caregiver.
• Utilizes knowledge of PACE guidelines and clinical processes and procedures in the development of nursing interventions.
• Demonstrates commitment to 24/7 participant care by participating in on-call, weekend, evening, and holiday on-call rotations.
• Works with interdisciplinary teams to ensure effective, cost-efficient care.
• Completes documentation accurately and in a timely manner.
• Other projects and duties as assigned.
RN Position Qualifications: • Licensed RN in the state of Kentucky.
Bachelor of Science in Nursing preferred.
• One year of nursing experience is required, preferably in a skilled nursing facility, home, or community health environment.
• Minimum 1 year of experience working with a frail or elderly population or must receive appropriate training upon hire.
• Must maintain CPR certification.
• Must have flexibility to travel to participant homes within the service area.
• Proficiency with technology-based tools, including electronic medical record.
• Able to work independently and as an effective member of a team.
• Excellent communication skills, with the ability to communicate with internal stakeholders at all levels of the organization and external stakeholders from varied backgrounds.
• Excellent organizational skills; able to multitask and maintain numerous initiatives with time sensitivity.
• Working knowledge of principles and practices of healthcare, healthcare systems, managed care, Medicare and Medicaid benefits and regulations.
• Knowledge of safety and infection control requirements for healthcare facilities.