Registered Nurse - Utilization and Care Transitions

Registered Nurse - Utilization and Care Transitions

Job Category: Clinical

Requisition Number: REGIS
003983

• Full-Time
• On-site

Senior Hlth Ctr-PACE, 4371 Latham Street, 1st Floor, Riverside, CA 92051, USA

Schedule: Monday-Friday, 8am-5pm. This position is onsite.

Care Coordination and Transition Management

• Act as the primary point of contact for transitions between hospitals, SNFs, and home care settings.
• Ensure timely and effective communication among all stakeholders, including physicians, discharge planners, and PACE interdisciplinary teams (IDTs).
• Monitor participant transitions to ensure compliance with regulatory requirements, including the timeliness of physician visits and follow-ups.
• Follow up on participant hospitalizations to ensure proper transitions to SNFs or home, ensuring compliance with new and existing regulations.

Relationship Building

• Develop and maintain strong relationships with Directors of Nursing, Case Managers, and other key staff at local hospitals and SNFs.
• Serve as a liaison to build trust and streamline communication between PACE and external providers.

Weekly Facility Visits

• Conduct weekly visits to contracted facilities to maintain a physical presence and reinforce relationships.
• Address any care-related concerns promptly and ensure participants receive quality care aligned with their care plans.

Regulatory Compliance

• Ensure all transitions of care meet the requirements outlined in federal regulations, including 42 CFR §483.30.
• Maintain accurate documentation of participant care and transitions in compliance with regulatory and organizational standards.
• Participate in IDT meetings to update the team on participant transitions and facility interactions.
• Collaborate with medical directors and providers to align care plans and ensure consistency of orders, medications, and treatments.

Access to EMRs

• Obtain and maintain access to facility electronic medical records (EMRs) to monitor participant care effectively.
• Document relevant participant data to support care coordination and oversight.

Oversight of Clinical Processes

• Oversee and ensure the timely completion of all required physician visits, including initial visits and routine follow-ups.
• Ensure orders for medications and treatments are in place and meet participant needs during transitions of care.

Participant Advocacy

• Serve as an advocate for PACE participants to ensure they receive appropriate care during transitions.
• Educate participants and their families on care plans and post-discharge instructions.
• The Nurse Navigator/Liaison will support up to 325 PACE participants to ensure effective care coordination and compliance.
• Perform other duties as assigned in support of departmental and organizational goals.

Education/Experience

• Bachelor’s degree in nursing required.
• Valid CA Registered Nurse License required. Registered Nurse (RN) with an active, unrestricted license to practice in the state.
• Minimum of 3 years of clinical nursing experience required, with at least 1 year in transitional care, case management, or utilization review. Experience in PACE, SNFs, or hospital settings is preferred.
• Current Basic Life Support (BLS) certification through an American Heart Association (AHA) approved source required upon hire and must be maintained as a condition of employment.
• AHA-approved courses include an in-person, hands‑on skills check with a certified instructor using a mannequin to demonstrate CPR and emergency response techniques.
• Online-only BLS courses without a live skills check do not meet this requirement.
• In addition, current CPR and First Aid certification are required for all PACE employees in accordance with CMS and DHCS requirements. First Aid training will be provided at onboarding and must be renewed annually.
• Valid CA driver's license and proof of auto insurance required.
• Experience working in risk‑based integrated models of care preferred.
• Certification in Case Management (CCM) or equivalent preferred.

Additional Qualifications (Knowledge,

Skills and Abilities

)

• Excellent verbal and written communication skills, including superior composition, typing and proofreading skills.
• Ability to interpret a…