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Registered Nurse, Riverside/San Bernardino, CA


Organization: IOA, Institute on Aging
Category: Nurse
Location: Riverside/San Bernardino, CA
Date Job Posted: January 25, 2021
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Registered Nurse - Inland Empire

You may think "old" when you think of Institute on Aging (IOA) because we offer services for seniors and are a 40+ year institute…. but you wouldn't be more wrong. While we do have a long-standing history in California, IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the "status-quo" and create new and more innovative ways to help aging adults and adults with disabilities maintain their quality of life. With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence and participation in the community, fulfilling our mission.

IOA's Community Living Services division is an innovative and revolutionary healthcare model that allows seniors and adults with disabilities to live at home longer by transitioning them out of nursing homes and back into the community by partnering with health plans and Medi-Cal. This inventive, nationally recognized model is one of the most promising for seniors to date, transforming their lives by providing them with a higher quality and more independent life and saving millions of dollars for healthcare systems. CLS is IOA's fastest growing division, expanding throughout California.

The HCBA Medi-Cal Waiver program within Community Living Services division provides care management services to persons at risk for nursing home or institutional placement. The care management services are provided by a multidisciplinary care team comprised of a nurse and social worker. The care management team coordinates Waiver and State Plan services (e.g., medical, behavioral health, In-Home Supportive Services, etc.), and arranges for other available long-term services and support available in the local community. Care management and Waiver services are provided in the Participant's community-based residence. This residence can be privately owned, secured through a tenant-lease arrangement, or the residence of a Participant's family member.

IOA's HCBA program-Inland Empire is seeking a full-time Case Manager/Registered Nurse (RN). This is a full-time position and temporarily remote first work model.

The Case Manager/RN will conduct comprehensive nursing health assessments of participants' medical needs, diagnose functional and cognitive abilities and environmental and social needs to determine which service(s) are required to meet participants' needs and preferences in the community. This position requires driving throughout Riverside and San Bernardino County depending on your assigned area with occasional cases out of your region.

Other key duties and responsibilities include, but may not be limited to the following:
  • RN is assigned a case load of which they are the "Nurse" part of the Case Management Team (CMT) for each client.
  • Ensures proper tracking, charting, progress notes and case records for each enrolled client within the time guidelines and is completed according to Agency policy and procedure. Documents patient intervention and response to intervention accurately, using established guidelines within MedCompass, a population health management software
  • Working with the Social Worker (SW) on their CMT participants, their legal representatives, circle of support, and primary care physicians
  • Develop a Plan of Treatment (POT) to mitigate risk and minimize disruptions in services and identify when services identified in the POT are available through friends, family, and/or publicly funded programs in order to:
    o. Develop goals associated with the participant's assessed needs, individual circumstances, and preferences.
    o. Mitigate risk and minimize disruptions in services.
  • Implement the POT, which includes identifying service providers and community resources to help assure the timely, effective, and efficient mobilization and allocation of the services
  • Identify (and train, if necessary), backup caregivers who are willing and able to provide unpaid support when waiver service providers do not arrive when scheduled.
  • Providing information, education, counseling, and advocacy to, and on behalf of participants
  • Establishing a care coordination schedule based on the needs and acuity of the participant as determined by their initial service needs assessment and subsequent reassessments
  • Monitoring the delivery of HCBA Waiver services to ensure participants are receiving services as authorized in their POTs
  • Monitoring the quality of the authorized services by maintaining ongoing contact with participants - including a monthly face-to-face visit or telephone call - to monitor for changes in health, mood, social integration, functionality, and overall well-being
  • Conducting annual face-to-face visits, reassessments, and care plan updates
  • Following up with the participant after Emergency Department and In-patient facility admissions
  • Ensures proper timekeeping and scheduling as discussed with their supervisor.
  • Be willing and able to implement any other program policies that lead to the successful outcome of the waiver program that arise throughout the term of employment.
  • Completes assessments and reassessments based on the timeline determined upon a
  • participant's enrollment in the program as well as following up with the participant after an Emergency Department and/or inpatient facility admission.
  • Alerts their Lead RN if any issues arise before, during or after an assessment is completed.
  • Completes assessments as part of the enrollment process.
  • Participates in Education, Training and Quality Improvement Activities as well as
  • assisting the Agency in maintaining compliance with Federal, State, Local and HIPAA Regulations and Joint Commission Standards.

    REQUIRED QUALIFICATIONS
  • Current, unencumbered license to practice as an RN in the State of California
  • One year of Registered Nurse experience
  • Current Basic Life Support (BLS) certification
  • Extensive travel around Riverside and San Bernardino County required
  • Must have own vehicle for transportation to and from work, including travel between worksites or other locations

    DESIRED QUALIFICATIONS
  • One year of case management experience
  • Bilingual English and Spanish capability

    We encourage you to learn more about IOA by logging onto http://www.ioaging.org

    For more information and to apply, visit: https://jobs.jobvite.com/institute-on-aging/job/oAqCdfwz

    IOA reserves the right to revise job descriptions or work hours as required. Institute on Aging is an Equal Opportunity Employer. Institute on Aging is committed to cultivating a diverse and inclusive work environment and providing equal opportunities to all employees and job applicants without regard to age, race, religion, color, national origin, sex, sexual orientation, gender identity, genetic disposition, neuro-diversity, disability, veteran status or any other protected category under federal, state and local law.





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