Participates as a member of the PACE Interdisciplinary Team in the planning, implementation and evaluation of care plans that meet the objectives, standards and policies of the PACE model of care. Assesses the participants’ needs for home care services and schedules, monitors and evaluates home care services. This position is full time Monday thru Friday 8am to 4pm with no weekend or holiday hours.

Essential Responsibilities:

• Performs initial assessments of participants in their home environments, within first week of enrollment, to determine their individual needs and to coordinate their initial care plans.
• Conducts, at minimum, annual in-home reassessments of all participants to determine what services are needed and appropriate.
• Provides home visits on an as needed basis to triage changes in medical, cognitive or functional status and updates the teams on an as needed basis.
• Offers solutions to revise or modify care plans to better meet the needs of the participants and participates in the care planning process.
• Completes appropriate authorization forms for home care services on a 90 day schedule.
• Effectively communicates with participants and families regarding home care services and addresses any and all issues/concerns within 3 working days, or immediately if necessary. Keeps the IDT informed of any and all issues/concerns.
• Participates in family meetings or case conferences, as necessary.
• Records and maintains accurate and timely documentation in the participants’ charts.
• Follows all LTC participants by performing monthly chart reviews and at minimum, annual assessments.
• Provides rotating coverage for after hours on-call system.
• Ensures that all interactions with participants, families and vendors are conducted in a manner that adheres to the highest standards of care and the highest degree of professionalism.
• Ability to pass a fit test. Position requires mask where seal is critical. Incumbent is required to not have facial hair that interferes with a tight seal of the respirator.
• Frequent local travel.
• Performs other duties as assigned.

Job Specification:

• Successful Completion of an Accredited R. N. Program.
• Bachelor of Science Degree in Nursing, preferred.
• Current Licensure as a Registered Nurse in the Commonwealth of Massachusetts.
• Current CPR certification.
• A minimum of 2 years of experience working with a geriatric population.
• A minimum of 2 years of working in a community health setting.
• Proof of Covid vaccines required.