Registered Nurse (PACE)

Position Title: Center Based Nurse

Department: PACE

Supervisor: Nurse Manager

Hours per Week: 40 

Pay Range:  The expected base pay for the position is $36-$65.02 per hour and may be increased based on other factors, such as language, certifications, etc.

Primary Function:

Provide comprehensive nursing care to PACE participants in the center setting, including assessments, medication administration, treatments, and coordination of care. Collaborate with the interdisciplinary team to ensure safe, high-quality services that promote participant independence and well-being. Provide home visits as needed.

Duties & responsibilities:

• Complete initial and semi-annual nursing assessments for participants.
• Implement physician orders and document all interventions in the electronic medical record (EMR).
• Conduct nursing assessments for pre-enrollees and complete the nursing section of the MDS; review and sign completed MDS forms.
• Develop and implement individualized nursing care plans for assigned participants. Manage medication plans, including ordering from the pharmacy, coordinating timely deliveries ensuring administration, and providing education to participants and caregivers to promote adherence.
• Collaborate with Contracted nursing agencies, Assisted Living Facilities, rest homes, and nursing facilities to ensure continuity of care.
• Perform monthly medication audits to ensure medications administered and dispensed at the center are not expired or compromised; document findings using audit tools.
• Provide nursing assessments and interventions according to daily schedules and episodic needs at the PACE center
• Administer immunization screenings and vaccinations per policy and procedure.
• Document all nursing interventions accurately using designated EMR tools.
• Establish and maintain collaborative relationships with participants and caregivers to enhance quality care.
• Report, document, and track infections, wounds, and falls; assist with data analysis and improvement initiatives; monitor vaccination administration.
• Support training, supervision, and competency evaluation of Medical Assistants and Health Aides in collaboration with the Nurse Manager and Center Manager.
• Provide clinical supervision, guidance, and resources for Medical Assistants and Health Aides at the PACE Center.
• Oversee and review data input by Medical Assistants and Health Aides to ensure accuracy and authorize documentation for the medical record.
• Participate in all clinical meetings (morning huddles, team meetings, intake, staff meetings) and designated family meetings.
• Participate in the on-call rotation as scheduled.
• Perform home visits as needed
• Perform other responsibilities as assigned by the Nurse Manager.

Minimum Basic knowledge:

• Proficiency in Microsoft Office applications, including Excel and Word.
• Strong written and verbal communication skills.
• Ability to collaborate effectively within an interdisciplinary team environment.
• Valid driver’s license and reliable transportation for home visits.
• Knowledge of infection control practices and home safety standards.
• Familiarity with electronic medical records (EMR) and accurate documentation standards.
• Understanding of medication management principles and patient education techniques.
• Ability to prioritize tasks and work independently in a home-based setting.

Experience & Qualification:

• Registered Nurse licensed to practice in Massachusetts.
• Valid driver’s license and reliable vehicle for home visits.
• Ability to work effectively with multicultural staff, participants, and caregivers.
• Ability to function as a collaborative member of an interdisciplinary team.
• Bilingual skills in Spanish, Portuguese, or Haitian Creole preferred.
• Minimum of 1-year experience working with the geriatric population.
• Discharge planning experience desirable.

• Proficiency in electronic medical records (EMR) systems and accurate documentation practices. Strong organizational and time-management skills for independent work in home settings.

Essential Functions:

• Perform initial and semi-annual nursing assessments and develop individualized care plans.
• Implement physician orders and maintain accurate documentation in EMR.
• Manage medications, including ordering, delivery coordination, and participant/caregiver education.
• Provide scheduled and episodic skilled nursing visits in the PACE and home setting.
• Collaborate with the interdisciplinary team on care planning and discharge coordination.
• Participate in team meetings, on-call rotation, and quality improvement activities.

• Ensure compliance with infection control and home safety standards.  Complete other duties as assigned by the Nurse Manager.

Physical Requirements: 

• Ability to travel to participant homes and community locations; must maintain a valid driver’s license and reliable transportation.
• Frequent standing, walking, bending, and reaching during home visits and nursing procedures.
• Ability to lift, push, or pull up to 25 pounds (e.g., medical supplies, equipment).
• Manual dexterity for performing nursing tasks and operating medical equipment.
• Visual and auditory acuity sufficient for assessing participants, reading medical records, and communicating effectively.
• Ability to tolerate exposure to various home environments, including potential allergens, pets, and varying temperatures.
• Capacity to respond quickly in emergency situations and perform CPR if required.

Supervisory Responsibility:

• Provide clinical oversight and guidance to Medical assistants, health aides, and nursing students during home visits as assigned.

• Collaborate with the Nurse Manager on performance improvement initiatives and quality assurance activities. Serve as a resource for Health Aides and caregivers regarding clinical questions and best practices.

Define Access Level to PHI:

Level 4: Authorized to access full health information. UCHC position and job responsibilities involve the provision of patient care and working as a clinical team member. Staff in this category level, although allowed full access, should only access the necessary information for each respective treatment encounter/circumstance.

Salary : $36 - $65