IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the status-quo and create new and more innovative ways to help aging adults and adults with disabilities maintain their quality of life. With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence and participation in the community, fulfilling our mission. The Community Health Registered Nurse implements and coordinates the plan of care for PACE participants who reside in facilities, including Residential Care Facilities for the Elderly (RCFEs), Skilled Nursing Facilities (SNFs), and other congregate living environments. This role collaborates with facility staff and Interdisciplinary Team (IDT) members to support appropriate discharges and transitions of care between hospitals, facilities, and the participant’s home. This is a per diem role with an expected workload of approximately 8 hours per week and a minimum commitment of two days per month. SPECIFIC RESPONSIBILITES: Implements, directs, supervises and evaluates nursing care for participants who reside in RCFEs, SNFs and other congregate settings, including: Conducts scheduled assessments and recurring monitoring visits as appropriate and as directed by the physicians. Evaluates the acute illnesses of assigned participants in collaboration with other clinic staff. Teaches, supervises and evaluates the participant and caregivers regarding nursing care needs and other related problems of the participant. Initiates preventative and rehabilitative nursing procedures as appropriate for the participant’s care and safety. Collaborates with facility staff and IDT members to support safe discharges and transitions of care, including: Serves as the primary point of contact between hospital discharge planners and the Participant’s IDT to ensure smooth and coordinated hospital discharges. Coordinates with other IDT members to arrange for transitional care stays. This includes ensuring the Participant has all necessary supplies, medications, and personal items and the accepting facility has all necessary paperwork and documentation. Serves as the liaison between the transitional care facility and the IDT to monitor the established goals for the transitional care stay, and help guide discharge planning and/or custodial placement decisions as indicated. Oversees the transition to long-term placements in RCFE and SNFs, when indicated, and provides on-going monitoring and care coordination with the IDT. Acts as a nursing consultant to other staff and provides health teaching and advocacy within his/her scope of practice. Actively participates in guiding participant care as a member of the PACE IDT. Serves as a liaison between facility staff and the PACE IDT. Ensures appropriate departmental documentation in the EHR for consistency with the clinic and homecare plan of care. Meets all the administrative requirements, including attending staff meetings. Actively participates in and encourages actions that promote good public relations and providing high quality care and extraordinary service to the participants, their families and friends, visitors and the community. Participates in QI activities, such as risk for skin ulcers, end of life, medication compliance, immunizations and access to medical and non-medical specialists. All other reasonably related duties as assigned.Education: Nursing degree from an accredited school required; Bachelor’s Degree in nursing preferred. Background and Experience: Current California Registered Nurse license. Public Health Nurse Certificate preferred. Preference will be given to those with experience in public health nursing, work with the elderly and/or acute care nursing. A minimum of two years of nursing experience required. Some supervisory experience preferred. A minimum of one-year experience with older adults is required. Ability to work as part of an interdisciplinary team with initiative, compassion, resourcefulness and flexibility. Independence in clinical practice. Computer literacy required. Bilingual skills preferred. Interest and willingness to work in a multilingual, multicultural environment. ADDITIONAL REQUIREMENTS: Ability to comprehend complex written material and verbal instructions Ability to communicate and speak clearly in English Compensation Range: $59 – $63/hourly This amount is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any specific employee, which is always dependent on actual experience, education and other factors. This range does not include any additional equity, benefits, or other non-monetary compensation which may be included. Institute on Aging reserves the right to revise job descriptions or work hours as required. Beware of Hiring Scams We are aware that some third parties have reposted our job listings in an attempt to scam applicants. Please be cautious and only apply through our official channels. Institute on Aging will never request payment or sensitive personal information such as Social Security numbers during the hiring process. All official communication will come from a verified IOA email address. If you receive any suspicious communication or requests, report them to talentacquisition@ioaging.org. All legitimate job openings can be found on the Institute on Aging Careers Page. We encourage you to learn more about IOA by visiting us here. IOA reserves the right to adjust work hours or duties when appropriate. Institute on Aging is an Equal Opportunity Employer. Institute on Aging is committed to cultivating a diverse and inclusive work environment and providing equal opportunities to all employees and job applicants without regard to age, race, religion, color, national origin, sex, sexual orientation, gender identity, genetic disposition, neuro-diversity, disability, veteran status or any other protected category under federal, state and local law. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. A job with benefits that goes above and beyond. From competitive salaries to investment and retirement opportunities, we offer our employees first-rate benefits. Coupled with outstanding health coverage, robust wellness programs, and additional perks, we make a rewarding career even more rewarding.