Registered Nurse, Care Manager-PACE; Riverside

Registered Nurse, Care Manager-PACE (Riverside)

Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision: a community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together.

As a private, non‑profit 501(c)(3) community health organization, we serve over 500,000 medical, dental, and behavioral health visits from more than 100,000 people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance.

Since 1969, our employees have been making this mission a reality. Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond. If this sounds like an organization you would like to be a part of, we would love to meet you.

We are seeking a Registered Nurse Care Manager to establish a well‑rounded care practice by incorporating patient assessment, implementing and coordinating care plans, and monitoring routine evaluations to ensure medically appropriate care. This role will facilitate Interdisciplinary Team (IDT) care coordination and intensive medical management for participants discharged from hospitals or skilled nursing facilities, and implement skilled nursing services.

Additionally, this position will work with the IDT Social Worker and Physician to collect necessary medical and social information to ensure comprehensive decisions are made to ensure the safety and well‑being of participants.

Schedule: Monday–Friday: 8 am–5 pm (1‑hour lunch)

Signing Bonus: Eligible for a $2,500 signing bonus.

• Manages the initial assessment for potential PACE participants, including home visits to support environmental and physical assessments
• Coordinates and completes semiannual assessments with 1:1 at PACE Multipurpose Center and/or at participant’s home for assigned case load
• Documents activities encountered between participants, families, caregivers, contracted providers, hospitals, skilled nursing facilities (SNF), and other facilities working together to ensure the well‑being of PACE participants in accordance with PACE policies, procedures, and regulatory requirements/laws
• Ensures implementation and compliance of participants’ care as ordered by providers
• Responds and manages medical emergencies based on necessary courses of actions dependent on the type of medical emergencies
• Provides RN clinical coverage in the PACE clinic
• Screens and triages participants, as needed
• Documents nursing care on the day service is rendered in accordance to established guidelines related to medical care provision
• Administers medications and treatments ordered by the physician/APP, including monitoring participant responses
• Participates on the Interdisciplinary Team to assess the nursing needs for participants
• Works with members of the interdisciplinary team (IDT), participants, and families in developing the plans of care for participants
• Maximizes participant functional capacity by encouraging autonomy in all aspects of care
• Educates, supervises, and counsels participants and/or caregivers regarding nursing care needs and other related problems
• Educates participants and families in safe administration of medication for home use, including assessing and encouraging compliance with medication regimen
• Initiates preventative and rehabilitative procedures or programs as appropriate for care and safety to participants
• Notifies appropriate medical personnel and IDT of changes in participant statuses
• Recognizes and understands the significance of abnormal test results to assist in gathering data, planning, and implementing care
• Provides safe total patient care to participants with complex health problems with a focus on individual participants and their families
• Maintains standards of nursing practice and follows hospital policies/procedures for care delivery and medication administration
• E…