PACE - Primary Care Nurse

Jacksonville, FL 32205 Works in the clinic to provide care planned services and acute care as needed. Works closely with the RN Care Managers and clinical team daily to perform duties such as delivering participant care, administering treatments, monitoring vital signs, performing tests, handling medical emergencies, and recording participant behavior. Assesses and monitors participants’ health status, provides nursing care, administers prescribed medications, educates, and counsels participants and families, in collaboration with primary care physician and other team members according to care planned services or as acute need arise. May assist with conducting initial assessments and periodic reassessments, plan of care, coordination of 24-hour care delivery, regularly informing the Interdisciplinary Team (IDT) of the medical, functional, and psychosocial condition of each participant, remaining alert to pertinent input from other team members, participants caregivers, as well as documenting changes in a participant’s medical record consistent with documentation policies established by the Medical Director.

• Perform clinical nursing duties with high integrity, quality, and under the clinical supervision of the Medical Director
• Conduct nursing visits which may include, but not be limited to lab draws, wound care, pregnancy tests, injections, BP checks, urine tox screens, pill counts, TB tests, etc. (as directed by providers)
• The RN will ensure participants are seen on a timely basis, identify and communicate barriers to efficient flow and identify possible solutions
• Perform basic in-house lab tests; obtain and process specimens for outside laboratories
• Take and record vital signs, recognize any variances, outliers, or red flags, and take appropriate action
• Serve as a back-up to the RN Care Manager to conduct in person comprehensive initial nursing assessments with new PACE Place enrollees.
• Serve as a back-up to the RN Care Manager to coordinate with the IDT (Interdisciplinary Team) to develop a comprehensive plan of care for each participant.
• Serve as a back up to the RN Care Manager to conduct in-person nursing reassessments semiannually and as needed
• Provides ongoing assessment, monitor health problems and health status as needed, and implements nursing care plans
• According to PACE Place policies and/or as directed by the Medical Director, provide medications, and conduct medication reconciliation
• Works with RN Care Manager to develop a plan to meet skilled, intermediate, and personal care needs, and set long and short-term goals
• Fill in for Home Care Manager as needed, conducting home visits, and initiating initial home assessments
• Assist and facilitate participants in obtaining medical services, including scheduling participants as appropriate, triaging participants, and assessing participants
• Communicates participant changes, collaborates on care planning decisions and coordination for 24-hour care as directed by the Provider
• As directed by the Clinical Manager participates in the Intake and Assessment meetings
• As directed, provides orientation, education, and initial and annual competencies of CNAs
• Effectively communicates in IDT (Interdisciplinary Team) Meetings, family meetings, and clinic meetings
• Provide participant triage and assessment and obtain health information and relevant data
• Observes, records and reports participant’s condition and reaction to drugs and treatments to physicians
• Maintains timely flow of participants
• Maintain pharmacy medication log, refrigerator, and room temperatures
• Responds to and performs triage of incoming telephone calls. Schedules outside appointments for participants when necessary
• Implements the orders written by primary care provider
• Notification of the provider of any marked change in the participant’s condition
• Provision of emergency care including arrangements for transportation
• Communicates with Members Services Coordinator to ensure specialist appointments are scheduled and assists in hospital admissions and calling report to unit
• Instructs and educates participants and family regarding medications and treatment instructions
• Maintains and reviews participant records, charts, and other pertinent information. Documents test and examination results.
• Minimal provision of Quarterly narrative nursing note, unless a participant’s condition requires a more frequent note, indicating participant’s progress toward achieving health goals

• Associate Nursing Degree required; BSN preferred
• Registered Nurse license
• BLS Certification required

• Minimum one-year working with the frail or elderly population
• One-year of experience as a Home Health or Long-Term Care Nurse or equivalent experience

• Demonstrated ability to work in an interdisciplinary team setting preferably with frail or chronically ill elderly persons
• Demonstrates knowledge of growth and development
• Exhibits appropriate communication skills necessary for ages served (Adult/Geriatric)
• Ability to perform diversified duties with time limitations with high degree of accuracy
• Ability to use problem solving, critical thinking and priority setting skills
• Organizational skills
• Must have, or obtain First Aid and CPR certification (from a certified provider) for this position due to participant contact