Job Description

San Diego’s St. Paul's PACE program (Program of All-Inclusive Care for the Elderly). This innovative program is for individuals 55 years or older, who are living with chronic illness, or disabilities and need coordinated medical care to continue living as independently as possible in their home and community. The healthcare teams at St. Paul’s PACE provide a hands-on approach coordinating medical, social, and home care services so individuals no longer need to manage their medical care alone.

Under the supervision of the Clinical Services Director, manages flow of clinic leading all staff in provision of medical and nursing care, ensuring high quality standards. Coordinates services with primary care team, acts as primary liaison. Triages, and assess participants as needed. Acts as gatekeeper for daily clinic scheduling. Provides skilled nursing care to participants, implements orders, develops appropriate plans of care, provide participant, caregiver, family, and staff teaching and communicating participant’s condition to caregivers, primary care, and the interdisciplinary team.

Duties and Responsibilities:

• Functions as the IDT facilitator, maintaining regular attendance and active participation in interdisciplinary team meetings; communicates participant changes and collaborates on care planning decisions to support coordinated 24-hour care delivery.
• Provides orientation and competency assessments and supervises and evaluates clinic nurses, nurse case managers, IHS nurses, and medical assistants.
• Update CAIR per regulatory standards and ensure staff accurately enter all vaccinations, maintaining quality metrics goals.
• Ensure accurate completion of assessments and plans of care in compliance with CMS/DCHS guidelines; confirm that all annual assessments include the required Level of Care forms.
• Monitor open incident reports and follow up on pending clinic reviews; investigate medication errors and provide coaching or corrective actions as needed.
• Maintains indirect supervisory oversight of day center care staff.
• Ensures clarity of job responsibilities, authority, and accountability for direct reports and ensures clinic staff practice within their defined scope.
• Promotes team building while coaching and mentoring staff. Provides instruction, teaching, and training to ensure clinic staff can function independently.
• Manages clinic flow and oversees appointment scheduling, triaging, and gatekeeping in collaboration with primary care and clinic staff. Ensures participants receive timely and appropriate care.
• Oversees and ensures timely sign-off of orders, coordinates medication ordering from the pharmacy, and disseminates orders and instructions to appropriate personnel. Ensures the implementation of physician orders. Run weekly orders reports and distribute to staff
• Coordinates participant care with outside contracted service providers, including nursing homes, assisted living facilities, wound provider, laboratories, DME company, and hospice agencies, as needed.
• Attends utilization meetings and assists in minimizing utilization by facilitating communication with contracted facilities. Ensures that all admissions are entered in a timely manner.
• Communicates with after-hours staff and contracted service providers regarding participant clinical care, including the review of participant care documentation.
• Manages and reviews participants’ records, charts, pertinent information, and staff documentation, documenting as needed in medical records according to St. Paul’s PACE standards. Conducts audit to ensure that RNCM provides at minimum a quarterly narrative nursing note, or more frequently if a participant’s condition requires, to indicate progress toward health goals.
• Performs general skilled nursing care to participants. Performs or supervises the administration of prescribed medications and treatments in accordance with nursing standards. Assist in treatment, examination, and testing of participants. Records all medications and treatments administered.
• Provides oversight of clinical staff phone lines, ensuring calls are answered promptly. Ensure staff return phone calls in a timely manner.
• Prepare and submit quarterly Medical Necessity Reports, including analysis of Part B vs. Part D medication coverage.
• Conduct monthly audits of the ATM system and other compliance-related processes.
• Educates participants, family and caregivers in regard to care, medications, and treatments. Responds to grievances within a timely manner.
• Provides educational in-services to staff on regulatory updates and ensures that the latest evidence-based practices are consistently followed.
• Monitors clinical departmental expenditures and meets budgetary expectations.
• Participates in and supports Quality Improvement initiatives, attending meetings regularly to monitor and promote ongoing department improvements.
• Follows all St. Paul’s PACE Policies and Procedures, and OSHA safety guidelines.
• Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants and families.
• Practices Universal precautions, and follows appropriate Infection Control procedures.
• Participates in continuing education classes and any required staff and training meetings. Maintains professional affiliations and any required certifications.
• Shall receive in-service training in first aid and in cardiopulmonary resuscitation within the first six months of employment.
• To ensure continuity of operations assumes the Center Directors responsibilities in her/his absence.
• Performs other duties as required or requested.

Qualifications and Requirements:

Education: BSRN strongly preferred. Current California Registered Nurses License and CPR certification required.

Experience – A minimum of one years’ experience working with a frail or elderly population required. Two years of nursing management experience in a hospital, nursing home or community-based setting preferred.

Skills/Knowledge

• Management and leadership skills.
• Broad knowledge base of health care problems of the frail elderly.
• Skilled in physical assessment and triaging.
• Knowledge of medical equipment and instruments.
• Knowledge of common safety hazards and precautions to establish a safe work environment.
• Skilled in identifying problems and recommending solutions.
• Skilled in preparing and maintaining records and writing reports, and responding to correspondence.
• Skilled in developing and maintaining department quality assurance.
• Skilled in establishing and maintaining effective working relationships with participants, medical staff, staff members and family caregivers.
• Ability to react calmly and effectively in emergency situations.
• Knowledge of home care services nursing principles and practices, with reference to the elderly.

St. Paul’s Benefits:
• Health, dental, vision, life
• Same day pay available!
• Flexible Vacation Time - 17 days!
• Paid Sick Time
• Education reimbursement - up to $3,000 a year!
• Qualified Public Student Loan Forgiveness (PSLF) employer
• 403(b) with match
• Child care available
• Employee referral bonuses
• Upward mobility!
You Make Us Who We Are!

At St. Paul’s Senior Services, we believe a diverse workforce has driven our history of enriching the lives of senior communities in San Diego, which is why we are committed to cultivating an environment where you feel empowered, supported and respected. By valuing your unique perspective, voice, strengths, experience and background, we aim to foster a culture where you feel included and comfortable being your true self. You matter!

St. Paul's is the leading provider of caring senior services since 1960. We have locations throughout San Diego County including 5 in San Diego (Bankers Hill), 2 in Chula Vista, and 1 in El Cajon. St. Paul's strives to be the most outstanding and innovative senior home and service provider in California. We are dedicated to serving the physical, spiritual and social needs of the elderly and community, fostering a culture of diversity and inclusion within the highest quality facilities, health care and programs consistent with affordable costs.

YOU MUST BE ABLE TO CLEAR FINGERPRINTS THROUGH DOJ AND FBI IN ADDITION TO A DRUG SCREEN CLEARANCE.

To learn more about St. Paul’s Senior Services, please visit www.stpaulseniors.org.

St. Paul’s Senior Services is an Equal Opportunity Employer