Clinical Care Manager (Registered Nurse)

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).