Role Summary:

Join our dedicated Interdisciplinary Care Team in Pasadena! This role involves working collaboratively to deliver and manage all aspects of participant care. You will conduct PACE assessments, develop individualized Care Plans, and advocate for participant needs. In partnership with the Primary Care Provider, you will deliver care in various settings, including participant homes and skilled nursing facilities, ensuring comprehensive management of participant and family care needs.

Duties and Responsibilities:

• Take ownership of outcomes and quality of care for assigned participants, working in tandem with the PCP and utilizing clinic resources.
• Conduct in-clinic, at home, and virtual PACE assessments, educate participants and support networks, and perform follow-up visits based on participant needs.
• Develop and implement a discipline-specific plan of care in collaboration with the IDT, participants, and families, ensuring high-quality, participant-centric care.
• Identify participant needs, determine priorities, and collaborate with the Primary Care Provider and other team members.
• Coordinate care for participants with complex needs, ensuring seamless transitions and preventing unfavorable outcomes.
• Attend to Clinical Inbox in collaboration with the PCP, ensuring timely completion of orders and follow-up on test results and documents.
• Perform and document procedures and care in clinic or at home as needed, in accordance with scope of practice.
• Communicate participant changes to the interdisciplinary team, including post-procedure or discharge needs and changes in care level or condition.
  
  

Skills:

Required Skills & Experience:

• Minimum of two years of nursing experience in a clinical setting with a frail or elderly population.
• Nursing knowledge and skills necessary to treat frail, elderly participants and manage complex clinical situations.
• Highly motivated, self-directed, and able to make sound decisions in emergency situations.
• Excellent clinical, organizational, and communication skills in settings with seniors, their families, and interdisciplinary team members.
• Ability to multi-task and contribute to projects, timelines, and process improvement initiatives.
• Strong ability to work independently with minimal supervision and prioritize in a fast-paced environment.
• Experience and competency working with people from diverse backgrounds and cultures.
• Commitment to unlocking the full potential of our most vulnerable seniors.
  
  

Preferred Skills & Experience:

• Bilingual English/Spanish preferred.
  
  

Education:

Required Education:

• Graduate of an Accredited School of Nursing.
  
  

Certifications & Licensure:

Required Certifications & Licensure:

• Unencumbered RN License
• BLS