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PACE Home Care Registered Nurse

Location : Modesto, CA
Job Type : Temp/Contract
Reference Code : PRF 7543
Job Industry : Healthcare - Health Services

Job Description :


Has the responsibility for providing direct and indirect nursing care to assigned patients in their homes and as assigned in the clinic. Manages complex clinical situations. Works under the supervision of the Home Health Coordinator for Administrative purposes, and under the Medical Director for clinical purposes.


  • Collects patient data and completes required forms with appropriate responses according to unit standards. 

  • Identifies patient’s overt clinical 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 critical thinking skills. 

  • Develops a plan of care based on nursing process and which incorporates the plans of other disciplines and continuing care needs; includes the patient/family in developing or revising the plan of care in coordination with the Interdisciplinary Team. 

  • Present prospective enrollee cases to the Interdisciplinary Team as needed. 

  • Prepares and oversees the semi-annual level of care on-site audit in coordination with other Interdisciplinary Team members. 

  • Makes referrals to multidisciplinary support services.

  • Performs initial and periodic assessments (minimally every six (6) months) to be completed prior to the scheduled team meeting. Communicates participant changes to team members. 

  • Implements Managed Care to conform to accepted practice standards. 

  •  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 in appropriate forms; provides participant and family education in coordination of 24 hour 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. 

  • Administers medications or monitors of self-administration of medications by participants. 

  • Supervises personal care given by program aides. 

  • Notifies the physician of any marked change in the participant's condition. 

  • 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. 

  • 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 PACE expectations to meet staffing demands based on patient care needs. 

  • Complies with policies addressing safe working conditions; monitors unsafe working conditions; recognizes inappropriate and/or ineffective patient care management, resolves issue/problem and completes written reports. 

  • Fulfills calls for unit as assigned and adjusts staffing for census (volume) and acuity.  Participates as a member of the Interdisciplinary Team. Attends staff meetings and takes part in participant care planning. 

  • Observes each participant for any change in physical, mental, emotional and social functioning and shall report such changes to the Interdisciplinary Team. 

  • Ensures that participants are oriented to the program and have opportunities to express their opinions about the care and services they receive. 

  • Ensures effective planning, implementation, evaluation and improvement of operational processes. 

  • Creates and implements processes to increase efficiency, improve utilization and manage costs. 

  • Supports general PACE maintenance activities to assure compliance with patient safety, infection control, quality assurance, mandated reporting, consent, and confidentiality policies/procedures. 

  • Conducts comprehensive nursing assessments and evaluations on prospective enrollees

  • Completes level of care documentation and submit for the state (DHCS) review initially and as required annually. 

  • Administers and completes the TB testing process for all the prospective enrollees 

  • As needed in the clinic, provide direct care that includes drawing lab orders, blood sugar checks, wound care and/or identified follow up needed. 

  • Other projects and duties as assigned

Required Qualifications :



 Minimum Qualifications

  •  Valid CA Driver’s License, acceptable driving record, and vehicle insurance. 

  • Ability to communicate skillfully, handle multiple priorities, maintain a warm and friendly demeanor, perform nursing duties, be flexible, innovative, focus on results and travel frequently or as required. 

  • Skilled in teamwork, excellent communication, data entry, computer applications and electronic health records. 

  • Must possess knowledge and skills necessary to treat patients; other training as required by department. 

  • Only act within the scope of his or her authority to practice. 

  • Meet a standardized set of competencies for the specific position description established by Central Valley PACE and approved by CMS before working independently. Education/Experience 

  • Graduate of an accredited school of professional nursing. 

  • Current unencumbered CA Registered Nurse (RN) License. 

  • Current BLS CPR Card certified by American Heart Association. 

  • Practiced nursing within the last three (3) years. 

  • Minimum three (3) years RN experience with at least two (2) years’ experience working with the frail or elderly population

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