Clinical Care Coordinator - Cantonese/Mandarin (RN License)
Core
Primary nurse care coordinator for a panel of PACE participants, managing comprehensive nursing assessments, care planning, and coordination across home, clinic, and hospital settings to support safe aging in place.
Role type
Clinical Care Coordinator (RN)
Builds
Coordinated medical care, transportation, meals, social activities, and medication management for low-income seniors
Domain
Healthcare / Elderly Care / PACE Program
Required skills
Registered Nurse (RN) license, comprehensive nursing assessments, care planning, interdisciplinary team collaboration, chronic disease management, medication reconciliation, home visits, clinical triage, wound care, IV therapy, phlebotomy, EHR documentation
Preferred skills
Bilingual (Cantonese and/or Mandarin), experience with frail/elderly populations, PACE training
Technologies
Electronic Health Record (EHR)
Responsibilities
Conduct initial, semiannual, and annual nursing assessments; present findings to IDT and develop individualized care plans; coordinate transitions of care between hospitals, SNFs, and homes; provide direct nursing care including wound care and injections; manage chronic conditions like CHF, COPD, and diabetes; educate participants and caregivers on self-management; maintain accurate documentation per CMS and regulatory requirements.
Seniority
Mid-level, hands-on IC