Pre-EnrollmentRN 

The Center for Elders’ Independence (CEI) provides a Program of All-Inclusive Care for the Elderly (P.A.C.E.) - a comprehensive healthcare model specifically designed for low-income, frail seniors. It combines medical and social services along with vigilant care planning and coordination in order to keep frail seniors safely living at home and in their communities. This unique and highly effective model utilizes an interdisciplinary team approach to care planning to drive high quality, affordable, integrated healthcare services to the elderly. 

Position Description: 

The Pre-Enrollment RN is responsible for assuring any person requesting enrollment into the PACE program can be cared for appropriately in a community setting and that they meet all requirements for PACE eligibility. The Pre-Enrollment RN performs assessments in person, reviews the assessments of other pre-enrollment Interdisciplinary Team (IDT) members to complete the DHCS Initial Level of Care (ILOC) documentation which summarizes the data gained during pre-enrollment eligibility assessment. This involves a review of all data collected to complete the assessment of the individual’s care support network, home environment, and their health condition to determine whether or not their health or safety would be jeopardized by living in a community setting. The Pre-Enrollment RN uses expert clinical skills, critical thinking and judgement, and is responsible for the evaluation of data collected by other clinicians, medical records and/or Interdisciplinary Team (IDT) members to determine if a person meets the minimum requirements for skilled and intermediate nursing needs. Documentation of this assessment and evaluation is the responsibility of Pre-Enrollment RN and may be required to respond to DHCS (state agency) for validation of skilled nursing needs, frailty, complex care needs and comorbidities as needed. The Pre-Enrollment RN must demonstrate clinical competency for the care of frail seniors. Nursing job duties are to meet the Nurse Practice Act, CMS PACE Regulations, Center for Elders’ Independence Code of Conduct, and professional education standards. 

Relevant Skills and Experience:  

• BSN Degree in Nursing, preferred.
• Minimum of two to five years’ experience in community based/healthcare hospital or tertiary care, required.
• 1 year minimum experience with the elderly population.
• Bilingual: Spanish/English or English/Cantonese/Mandarin, preferred.
• Demonstrates clinical competency and technical skills for the elderly patient population.
• Demonstrates knowledge of regulatory requirements in delegation of tasks to clinical support staff.
• Ability to prioritize Provider requests i.e. testing or other procedures related to patients visit and/or required follow up care.
• Excellent verbal and written communications including demonstrated strong interpersonal and presentation skills.
• Strong organizational and analytical/problem-solving skills in participant care environments.
• Demonstrates ability to function independently, evaluate and guide other Interdisciplinary Team (IDT) members to collect appropriate information or data that help facilitate the completion of assessments, determine skilled or intermediate nursing needs for submission for enrollment into PACE.
• Demonstrates knowledge and apply all regulatory requirements in completing nursing assessments, delegation of tasks and proper documentation.

Physical and Travel Requirements: 

• Ability to sit, stand, stoop, reach, lift (up to 10 pounds), bend, etc., hand and wrist dexterity to utilize computer.
• May require travel to sites/program and special functions.
• Environmental Conditions Critical to Performance:
  • May have some exposure to outside environments while traveling.
  • May be required to perform work duties in the community, patient homes or PACE Centers.

Essential Job Functions: 

• Conduct nursing assessments and examination to assess for eligibility while using motivational interviewing techniques, use of evidence-based tools, such as the frailty index for elders (FIFE) and identify participants who may meet the high risk health and safety denial guidelines for the PACE program.
• Perform physical examination, chart review and integrate other interdisciplinary team member’s assessments in evaluating eligibility criteria and minimum level of care (skilled nursing) for enrollment into the PACE program.
• Perform any necessary screening, interventions, diagnostic testing, or medication review to assure comprehensive evaluation of minimum eligibility requirements necessary for enrollment.
• Initiate huddles with the center anchor physician/provider team and other/or key disciplines to discuss individuals who may meet the criteria for denial based upon on the high risk, health and safety guidelines and ensure additional assessments are conducted timely
• Determine if sufficient data supports that the prospective PACE enrollee’s health or safety would be jeopardized by remaining in a community setting or enrollment into the PACE program using the Health & Safety High Risk criteria, the Pre-Enrollment RN works collaboratively with the PACE Intake Specialist to request denial of enrollment.
• Collaborate and participate with PACE Intake Specialist to present assessment and ILOC data to the center Interdisciplinary Team (IDT).
• Completes assigned nursing training and competency validation requirements on time.
• Perform all other related duties as assigned.