Work Type: Per Diem, As needed, PRN. 

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.

Performs all activities related to nursing care to achieve program goals and/or contracted service requirements at the PACE Center and the participant’s home. Manages complex clinical situations for which this position is responsible. The Registered Nurse reports to the Nurse Practitioner or other PACE Primary Care Provider.

Primary Duties and Responsibilities:

Clinical Functions:

• Performs and/or oversees the nursing functions of Esperanza’s PACE program.
• Conducts an initial nursing assessment and scheduled and as-needed reassessments for all PACE participants.
• Performs all functions and duties as required as a member of the PACE Interdisciplinary Team (IDT), including, but not limited to, participation in IDT meetings, family conferences, grievances, service determination requests, CMS audits.
• Coordinates with IDT in developing individualized plans of care for each PACE participant.
• Serves as on-call clinical staff after hours when designated and coordinates with the Advanced Practice Registered Nurse (APRN) or PACE physician to address urgent and emergent clinical needs.
• Takes off and implements PACE Medical Director orders, coordinating with other staff members as necessary.
• Develops a plan of care based on the nursing process which incorporates the plans of other disciplines and continuing care needs.
• Documents pertinent information related to participant encounters in the EHR, at the point of service or immediately following.
• Updates care plans with changes in participant status.
• Completes documentation of all visits (including episodic, routine, phone calls, home visits, etc.) against the corresponding care plan elements.
• Reviews medical records to ensure that appropriate information such as labs, specialist reports, and diagnostic test results are captured in the medical record.
• Facilitates communication via email, phone, and face-to-face meetings with key agency staff to maintain project flow/contracted timeframes.
• Supervises Licensed Practice Nurses.
• Bilingual (preferred).

• Must possess and provide annually valid driver’s license and documentation of current automobile insurance at PACE organization-specified levels.
• Must provide negative TB certificate, or documentation to support exemption, annually.
• Must comply with requirements of other facilities (hospitals, LTC (Long Term Care) facilities, etc.) related to flu or other vaccines if job duties require providing services in those facilities.
• Graduate of accredited nursing program.
• Minimum of Associate Degree in Nursing required; Bachelor’s degree in Nursing preferred.
• A valid Illinois RN license plus a minimum of one year of direct service experience with older adults and/or individuals with chronic diseases.
• Must be certified in CPR/BLS (Basic Life Support) by the American Heart Association.

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