Clinical Care Manager (Registered Nurse)

Job description

Imagine a center where our seniors can receive transformative health care that will allow them to age at home and in their communities. At Asian Health Services, we recognize that so many of our elderly patients continue to struggle to get the care they need because of challenges that go beyond the walls of the clinic. To address these gaps, we’ve found a solution and model of care that integrates the quality care our elders receive at our health center with the most comprehensive support system, like transportation, culturally-inclusive meals, and social activities, our elders deserve. We are building a **Program of All-Inclusive Care for the Elderly (PACE)** to bring life-changing, culturally competent care to low-income seniors—supporting them as they age safely and with dignity, right in their communities. Based on the PACE model, **SpringLight Health** will offer coordinated medical care, transportation, meals, social activities, medication management, and caregiver support—all tailored to each individual’s needs. Learn more by visiting our website [here](https://asianhealthservices.org/san-leandro-capital/pace/). **Job Summary:** The Clinical Care Manager (RN) serves as the primary nurse leader for the PACE clinic overseeing day to day clinic operations. The clinic care manager will also be the nurse case manager for an assigned panel of participants, responsible for comprehensive nursing assessment, care planning and effectuation, care coordination across settings (PACE center, home, contracted providers, hospital/SNF), and proactive management of chronic conditions to support participant safety, independence, and quality of life. ### Essential Job Functions - **Clinical leadership** - Supervise, mentor, and evaluate nursing and clinical staff (RNs, LPNs, CNAs, medical assistants); oversee staffing, scheduling, and performance to ensure continuity and accountability. - Monitor participant outcomes and clinical workflows to ensure timely assessments, interventions, and follow-up, thereby optimizing care quality and participant well-being. - Address participant emergencies and complex clinical cases by offering clinical guidance and ensuring comprehensive, coordinated care. - Partner with the Quality Improvement (QI) team in infection control initiatives by analyzing data, identifying trends, and implementing evidence-based corrective actions. - Ensure cilnic compliance with CMS, the SAA, OSHA, CDC, and PACE policies by maintaining audit readiness and accurate documentation within the EHR. - Plan, lead, and assess staff education and training programs, promoting evidence-based practice and ensuring licensure, certification, and competency standards are achieved. - Engage actively as a member of the PACE leadership team, helping shape strategy, policy, and program growth while advocating for nursing perspectives in decision-making forums. - Participate in required IDT, leadership, and nursing on-call rotations, reporting on participant clinical status and supporting after-hours coverage as needed. - **IDT participation and care planning** - Conduct initial, semiannual, and annual nursing assessments and update the participant record per PACE requirements. - Present assessment findings to the IDT; collaborate to develop and update the participant’s plan of care, including measurable goals and interventions. - Ensure care plan interventions are **implemented (effectuated)** and tracked; follow up on barriers and gaps with IDT members and external providers. - **Longitudinal care management** - Provide ongoing clinical oversight for an assigned participant panel, including routine monitoring, triage, and early identification of change in condition. - Coordinate preventive care and chronic disease management (e.g., CHF, COPD, diabetes), health maintenance, and risk factor reduction. - Provide participant and caregiver education aligned to the care plan (self-management, medication adherence, symptom monitoring, etc.). - **Transitions of care** - Coordinate care during transitions to/from hospital, emergency department, SNF, and home. - Communicate with hospital/SNF case managers and treating teams; support safe discharge planning, timely post-discharge follow-up, and reconciliation of orders. - Arrange post-acute services and DME/supplies as indicated by the plan of care. - **Direct nursing care and clinical interventions** - Provide direct nursing care within RN scope as needed (e.g., wound care, injections, IV hydration/therapies per policy, specimen collection/phlebotomy if applicable). - Carry out and document nursing interventions and provider orders accurately and timely in the EHR. - Triage participant symptoms (in person, by phone, and/or virtually) and escalate appropriately to the PCP/NP/Medical Director. - **Medication-related coordination (in collaboration with Pharmacy/Providers)** - Support medication reconciliation, monitoring for adverse effects, and coordination with the pharmacy team and prescribers. - Identify and communicate medication adherence issues and safety concerns to the IDT and providers. - **Documentation, compliance, and quality** - Maintain complete, accurate, timely documentation consistent with PACE policies and regulatory requirements. - Participate in quality improvement, infection prevention, and safety activities; report incidents and follow through on corrective actions. - Support audit readiness and adherence to CMS/DHCS PACE requirements and organizational policies. - **Teamwork and culture** - Collaborate respectfully with participants, caregivers, and colleagues; contribute to a welcoming, culturally responsive center environment. - Participate in required meetings, trainings, and on-call/after-hours coverage as applicable. - **Working Conditions** - Work occurs in the PACE center and in the community (participant homes, hospitals, SNFs, specialty offices) as needed. Ability to travel locally; may require a valid driver’s license and reliable transportation if home/community visits are part of the role. Ability to lift/move supplies and perform clinical tasks consistent with RN role requirements. ### Minimum Qualifications - Graduate of an accredited School of Nursing. - Minimum **2 years** experience working with a frail or elderly population (or completion of documented PACE training prior to independent care), consistent with CMS requirements. - Demonstrated ability to work collaboratively with teams to perform comprehensive assessments, clinical triage, and care coordination across care settings. - Bilingual ability (e.g., Cantonese, Mandarin) and experience providing culturally and linguistically appropriate services. - Ability to document in an Electronic Health Record (EHR) and use standard office software. - Must meet PACE program competency requirements for the role prior to working independently. - Must be medically cleared for communicable diseases and have up-to-date immunizations/vaccines per policy. - Ability to make home visits as appropriate and assigned. ### Preferred Qualifications - 3+ years of RN experience with medically complex older adults and/or community-based geriatrics. - 1–2+ years of care management/case management experience. - Experience in capitated models (PACE, Medicare Advantage, managed Medicaid) and/or home health. - Wound care certification and/or case management certification. ### Certifications, Licenses, Registrations - Current Registered Nurse (RN) license in good standing in California (or ability to obtain as required). - Current CPR/BLS certification (or ability to obtain within required timeframe).