Position Summary:

This position is responsible for contributing to the health and well-being of SD PACE participants as an interdisciplinary IDT team member, providing direct and indirect nursing care to participants. This position requires independent application of advanced nursing knowledge and skills, as well as collaboration with multiple disciplines of the IDT team to ensure the highest level of health and safety for beneficiaries, including managing complex clinical situations for which he/she is responsible.

Essential Functions of the Job:

• Assessment: Collects patient data and completes required forms with appropriate responses according to unit standards; identifies patient’s overt problems/needs and sets priorities; identifies problems requiring further referral and/or follow-up; interprets and records latest diagnostic results; performs advanced nursing assessment using sound judgement and critical thinking skills.
• Planning Care: Develops a plan of care based on sound nursing process, incorporating the plans of other IDT disciplines and continuing care needs; includes the patient/family in developing or revising the plan of care and goal setting; makes referrals to multidisciplinary support services.  Initial and periodic assessments (minimally every 6 months) to be completed prior to the scheduled team meeting. Communicates participant status changes to all IDT team members.
• Implementing/Managing Care: Care provided conforms to accepted practice standards for nursing and PACE programming; provides correct treatments/procedures and other care as prescribed and according to patient care standards; demonstrates understanding of age-related characteristics and needs of patients served; explains nursing procedures via appropriate formats; provides participant and family education in coordination of 24-hour (around the clock) care delivery; identifies emergency situations and independently initiates advanced therapy; acts as coordinator of patient care with other health care personnel and evaluates patient care measures instituted; understands and demonstrates respect for patient rights and utilizes established mechanisms for management of ethical issues in patient care.  
• Evaluation: Records patient care delivered as planned and any variation, with appropriate rationale; makes and records observations related to impending or associated problems; implements nursing measures related to impending or associated problems.  
• Leadership: Using nursing process, delegates nursing care to appropriate personnel; integrates cost effective measures into nursing practice; recognizes unit problems and takes responsibility for documenting same; demonstrates active participation in QI processes; complies with directives and SD PACE expectations to meet staffing needs based on patient care needs; complies with policies addressing safe working conditions; reports and monitors unsafe working conditions; recognizes inappropriate and/or ineffective patient care management, trouble shooting and problem resolution skills,  completes written reports as necessary; fulfills call for unit as assigned and adjusts staffing for census (volume) and acuity.  
• Participates as a member of the Interdisciplinary Team.  Attends staff meetings and contributes meaningfully to participant care planning. 

Additional Duties and Responsibilities

• The nurse will occasionally be responsible for conducting timely and comprehensive assessments of participants in various settings, including their homes and skilled nursing facilities. These assessments may include initial evaluations, routine follow-ups, and as-needed visits to support care planning, ensure compliance with PACE requirements, and promote participant safety and well-being. The ability to travel to different sites and work independently in the field is essential. Travel time will be included as paid time, and mileage will be reimbursed.
• Keeps abreast of all regulations and standards to ensure compliance with orders or directives issued by duly constituted government / regulatory agencies.
• Enhance professional growth and development through participation in educational programs, current literature, in-service meetings and workshops.
• Attends meetings as required and participates on committees and directed.
• Perform other related duties as assigned or requested.

Job Requirements

Experience Preferred:

• 6 months experience working with the frail and/or elderly population. Knowledge and or experience working in senior or elder care setting – PACE, Nursing Home, Hospice, ADHC, etc.
• Nursing competency and familiarity with care paths, interactive tools commonly used in skilled nursing home settings. 
• Must be able to triage clinical symptoms, apply care paths and clinical interactive tools in patient evaluation and care prior to communications with physicians. 
• Must be comfortable starting IV lines, IV medication administration and monitoring. 
• Must be comfortable with acute care of frail adults, complex wound care, and cognitively impaired adults. 

Education Required:

• Graduate of an accredited school of nursing 

Certifications Required:

• Valid, unrestricted CA RN license
• BLS certification

Verbal and Written Skills Required to Perform the Job:

• Excellent oral, written, and interpersonal communication skills.
• Ability to read, write and comprehend medical information and terminology.
• Ability to effectively present information, both verbal and written.
• Demonstrated knowledge of the RN scope of practice.
• Good interpersonal skills

Technical Knowledge and Skills Required to Perform the Job: 

• Possess the skills to provide high quality care for geriatric patients.
• Must thrive in team environment, possess good organizational and supervisory skills, and have the ability to effectively handle difficult and unusual interpersonal situations.
• Meet a standardized set of competencies for the specific position description established by San Diego PACE and approved by CMS.
• Demonstrated ability to be culturally sensitive and respect diversity, work effectively with individuals of different cultures and socio-economic status; passion for service; self-starter and highly organized; ability to prioritize and complete a large volume of work within strict deadlines; provide prompt, efficient and responsive customer service.
• Knowledge of video conferencing software and Microsoft Office, including Word, Excel, and Power Point. Knowledge of Electronic Health Records (ie. EPIC, True Chart, Nextgen)

Equipment Used:

• EPIC EMR Experience 
• Minor medical equipment such as vital signs monitors, emergency cart, automated external defibrillator (AED), and patient personal assist devices.
• Networked computer with various applications, fax machine, document center, and telephone.

Working Conditions and Physical Requirements:

• Physical clearance for reaching, bending, stooping, crouching, kneeling, and grasping; have full range of motion; ability to lift 50 lbs; need to lift and participants.
• TB clearance; must maintain current BLS Certification.
• Frequent standing and walking; Will be required to occasionally travel to other sites or other locations in San Diego County.

Universal Requirements

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and boosters is a term and condition of employment.

About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment.  Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.