Job Description

Schedule: Per diem/PRN-dayshift, M-F hours only (no weekend or holidays)

Compensation: $45/hour

What is PACE?

PACE, or Program of All-Inclusive Care for the Elderly, is an alternative care model for those over 55 years of age requiring nursing home level of care which aims to keep participants living at home in the community. PACE is a collaborative, interdisciplinary approach which coordinates all levels of medical and social needs, including prevention, wellness, socialization, primary care, and access to specialists and other services. The Registered Nurse (RN) supports and coordinates the clinical care needs of PACE participants through comprehensive nursing assessment, monitoring, care coordination, and communication of clinical concerns and recommendations to the PACE Interdisciplinary Team.

Primary Duties and Responsibilities:

• Perform and oversee nursing functions within the PACE program.
• Conduct initial nursing assessments, scheduled reassessments, and as-needed reassessments for PACE participants.
• Develop, implement, and update individualized participant care plans in collaboration with the Interdisciplinary Team (IDT).
• Monitor participant conditions and communicate changes in health status, clinical concerns, and recommendations to providers, IDT members, participants, and caregivers.
• Implement provider orders and coordinate services with internal departments, contracted providers, and community vendors.
• Complete accurate and timely documentation within the electronic health record (EHR), including participant visits, telephone encounters, home visits, assessments, and care coordination activities.
• Review participant medical records to ensure laboratory results, specialist reports, diagnostic findings, and other clinical documentation are appropriately maintained and incorporated into the medical record.
• Participate in participant-related activities and meetings, including Interdisciplinary Team meetings, family conferences, grievances, Service Determination Requests (SDRs), appeals, and regulatory reviews.
• Provide clinical supervision, guidance, and oversight to Licensed Practical Nurses (LPNs) as assigned.
• Assist with onboarding, orientation, staff training, and ongoing clinical education initiatives.
• Support infection prevention and control efforts in collaboration with organizational leadership, the Medical Director, and the PACE Site Director.
• Collect participant data and complete required reports, assessments, and documentation in accordance with regulatory and organizational requirements.
• Participate in quality improvement, quality assurance, and compliance activities, including medical record audits and corrective action initiatives.
• Maintain readiness for federal, state, CMS, and organizational surveys and audits.
• Coordinate care and facilitate communication among participants, caregivers, hospitals, long-term care facilities, contracted providers, and community partners to ensure continuity of care.

Requirements

Education

• Licensure Graduate of an accredited school of nursing.
• Current, unrestricted Registered Nurse (RN) license in the State of Illinois.
• Current Basic Life Support (BLS) certification required.

Experience

• Minimum of one (1) year of clinical nursing experience required.
• Experience working with frail elders, geriatric populations, home health, long-term care, hospice, or within a PACE program preferred.
• Experience coordinating care across multiple healthcare settings preferred.

Knowledge, Skills, and Abilities

• Ability to work effectively within an Interdisciplinary Team (IDT) model.
• Strong clinical assessment, critical thinking, and clinical judgment skills.
• Excellent verbal and written communication skills with the ability to effectively interact with participants, caregivers, providers, and community partners.
• Strong organizational skills with the ability to prioritize tasks, manage multiple responsibilities, and meet documentation deadlines. Ability to accurately complete clinical documentation and maintain detailed participant records.
• Proficiency with electronic health record (EHR) systems and Microsoft Office applications preferred.
• Bilingual English/Spanish preferred.
• Ability to maintain confidentiality and comply with HIPAA, CMS, state, federal, and organizational requirements.

Transportation and Travel Requirements

• Must possess a valid driver's license and maintain an acceptable driving record.
• Must have reliable transportation and maintain automobile insurance at organization-required coverage levels.
• Ability and willingness to travel to participant homes, hospitals, nursing facilities, specialty appointments, and community locations as required.
• Health and Compliance Requirements Must provide annual tuberculosis (TB) screening documentation or approved exemption in accordance with organizational policy.
• Must comply with all vaccination, health screening, and credentialing requirements of Esperanza Health Centers and affiliated healthcare facilities as required for job duties.
• Must successfully complete all required background checks, drug screenings, and employment verification processes.

Esperanza Health Centers is an Equal Opportunity Employer (EOE) according to Title 44, Ill. Administrative Code, and Subpart C Section 750.150.