Position Summary: 

Under the supervision of the Transitions and Care Coordination RN Manager, the Home Care Coordination RN Supervisor oversees the San Diego PACE Home Care Coordinators (RN and HHA) and Telephone Triage Team, ensuring the health and safety of San Diego PACE clients in their homes, including but not limited to: conducting home safety evaluations and routinely assessing the needs of clients in their homes to ensure they are receiving appropriate services, and professional IDT contributions from this team.

This role will assess the quality, efficiency, and accessibility in the provision of PACE services in home.  The Home Care Coordination RN Supervisor will set expectations for the planning, implementation, organization, and coordination of services to ensure home safety for San Diego PACE participants, consistent with CMS and DHCS requirements. This supervisor will also work in conjunction with the IDT Moderators and site leadership to oversee that all Care Coordinators are doing the same. The Home Care Coordination RN Supervisor is responsible for leading and managing the provision of caregiving and other home health services, ensuring high quality standards within the Home Care Coordination Department. Responsibilities include but are not limited to setting standards for documentation; determining appropriate assessments and tools to be used by department staff; ensuring policies and procedures are up to date; performing technical training; auditing documentation adherence and quality; monitoring and communicating changes to regulations; and guiding performance improvement efforts. The Home Care Coordination RN Supervisor serves as the technical expert for the discipline.

Additionally, the Home Care Coordination RN Supervisor will serve as the primary point-of-contact for escalation of overall service needs, including, but not limited to caregiving, home health, and DME agencies contracted by San Diego PACE to provide care giving services in participant homes. This position partners with the IDT/Center Managers to provide matrixed supervision and clinical support to Home Care Coordination team members as needed.

Essential Functions of the Job:

• Supervises a robust Care Coordination program that helps participants develop, regain, or maintain their highest potential for functional performance.
• Provides guidance and monitors related work ques of Home Care Coordination staff.
• Ensures assignments and accountability for outcomes; communicates and enforces values, policies, and procedures.
• Conducts qualitative reviews and assesses documentation of medical records for completeness and relationship to the treatment plan and identifying gaps or barriers in treatment plans, escalating, and resolving as appropriate.
• Develops and implements appropriate/required Home Care Coordination protocols and monitors that the Home Care Coordination team follows all protocols.
• Provides direct and indirect supervision of discipline specific staff through monthly audits of medical records and direct observation of the provision of services.
• Ensure appropriate Home Care Coordination resources are shared with IDT, to ensure timely and efficient problem solving.
• Responsible for conducting regular Home Care Coordination Team Meetings, training and on-going review of policies and procedures.
• Ensures timely and efficient handling of complaints, concerns, and resolves any Home Care Coordination matters to ensure the highest quality of services to our PACE participants and their families.
• Ensures coordination of services provided in the home, under the purview of this discipline and captured within the discipline care plan.
• Sets standards for coordination of care and understands and demonstrates respect for patient rights, utilizing established mechanisms for effective management of ethical issues in patient care.
• Demonstrates active participation in San Diego PACE QA processes; is involved in assessment and implementation of QA improvement plans.
• Assists with the planning and preparation of the San Diego PACE CMS audit.
• Establishes Home Care Coordination operational strategies by evaluating needs; establishes critical measurements; determines production, productivity, quality, and patient service strategies.
• Integrates cost effective measures into Home Care Coordination practice.
• Responsible as assigned for after business hours, weekends, and holidays coverage.
• Complies with policies addressing safe working conditions; monitors unsafe working conditions; recognizes inappropriate and/or ineffective patient care management, resolves issues/problems, and completes written reports; fulfills call for unit as assigned and adjusts staffing for census (volume) and acuity.
• Ensures that all new Home Health staff are on-boarded, annual competency assessments are completed, licenses renewed and documented in the personnel files.
• Assists other departments and sites as required.
• Other duties as assigned

Additional Duties and Responsibilities:

• Maintain and follow established departmental policies and procedures, objectives, quality assurance program, safety, environmental and infection control standards.
• Enhance professional growth and development through participation in educational programs, current literature, in-service meetings, and workshops.
• Adheres to and models SYH’s core values and behaviors of Excellence, Empowerment, Integrity, and Respect.
• Adheres to SYH and PACE attendance and punctuality policies and practices.
• Attend meetings as required and participate on committees as directed.
• Perform other related duties as assigned or requested.
• Acts only within the scope of his or her authority to practice.
• Practices standard infection control precautions.
• Maintains safe working environment, following safety policies and procedures.
• Participates in continuing education classes and any required staff and training meetings.
• Maintains professional affiliations, required certifications and continuing education requirements.

Job Requirements

Experience Required:

• Currently practicing RN, with at least 1 year RN experience, including at least 9-months experience working with frail elderly populations within a PACE program and demonstrated progressive leadership skills and responsibilities.

Experience Preferred:

• At least 1 year of demonstrated progressive leadership skills and responsibilities. Knowledge and or experience working in senior or elder care setting - PACE, Nursing Home, Hospice, ADHC.
• Nursing competency and familiarity with care paths, interact 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.

Education Preferred:

• Bachelor’s Degree (BSN)

Certification Required:

• Current, unencumbered RN license in California state; must present credentials which demonstrate ability to meet performance criteria for an RN
• Active First Aid, CPR and (American Heart Association) 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.

Technical Knowledge and Skills Required to Perform the Job:

• Must possess the skills to provide care for geriatric patients
• Must thrive in a team environment, must possess good organizational and supervisory skills, including 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)

Competency:

• Position specific competencies for the Home Health RN must be met prior to assuming participant care.

Equipment Used:

• Minor medical equipment such as vital signs monitors, emergency cart, automated external defibrillator (AED), and patient personal assist devices.
• Networked computer with various applications, facsimile 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; Frequent standing and walking
• Will be required to occasionally travel to other sites or other locations in San Diego County.
• Need to lift and transfer participants
• TB clearance; must maintain current First Aid, CPR and BLS Certification.

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 all 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.