This remote telehealth position involves conducting nursing assessments, reassessments, monthly monitoring visits, and care coordination for participants in the Assisted Living Waiver (ALW) and/or California Community Transitions (CCT) programs. The role requires working independently, using sound clinical judgment, and ensuring accurate and timely documentation while escalating clinical or safety concerns appropriately.
Responsibilities
Conduct initial nursing assessments for ALW and/or CCT participants
Complete participant reassessments by telehealth to evaluate current health status, functional needs, medical concerns, safety risks, and support needs
Assess participant’s medical history, diagnoses, medications, ADLs, mobility, cognition, fall risk, skin concerns, nutritional status, psychosocial needs, caregiver support, and environmental safety concerns to the extent possible through telehealth
Ask appropriate follow-up questions to identify changes in condition, unmet needs, or risks that may require further evaluation
Recognize when telehealth assessment is not sufficient and escalate the need for in-person follow-up, provider evaluation, emergency care, or supervisor review
Document all assessment findings clearly, accurately, and within required timelines
Complete monthly monitoring visits as assigned
Conduct visits remotely by telephone and/or audio-video telehealth platform
Monitor participant status, including any changes in condition, ER visits, hospitalizations, falls, medication concerns, wounds, behavioral concerns, caregiver issues, or changes in living situation
Confirm services and supports are being provided as planned
Identify and report unmet needs, barriers to care, or participant safety concerns
Follow up with participants, caregivers, facilities, and program staff as needed
Document each monthly visit and all follow-up actions timely and accurately
Coordinate with participants, families, caregivers, assisted living facility staff, physicians, home health agencies, hospice agencies, pharmacies, DME providers, discharge planners, and other community providers as appropriate
Assist with care coordination related to participant stability, safety, and continued community placement
Communicate significant health changes or concerns to the appropriate supervisor, case manager, physician, facility staff, or care team member
Support transition planning and post-transition monitoring for CCT participants as assigned
Help ensure services are coordinated to support participant needs and prevent avoidable complications, hospitalizations, or placement issues
Complete all required ALW/CCT nursing documentation accurately and timely
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Document assessments, reassessments, monthly contacts, care coordination activities, participant concerns, clinical findings, and follow-up actions
Ensure documentation supports participant needs, safety concerns, and services provided
Maintain documentation in accordance with agency policies, program requirements, HIPAA, and applicable state and federal regulations
Submit completed documentation by assigned deadlines
Maintain confidentiality of participant information while working remotely
Maintain a private and professional remote work environment
Ensure participant privacy during all phone and video encounters
Verify participant identity as appropriate before discussing health information
Use agency-approved systems for documentation, communication, and telehealth visits
Maintain reliable internet, phone access, and ability to use required electronic systems
Keep all participant records and electronic information secure
Notify supervisor promptly of technical issues, missed contacts, inability to reach participants, or barriers to completing assigned visits
Monitor for signs of decline or risk, including falls, medication issues, wounds, infection symptoms, mental status changes, functional decline, caregiver instability, abuse or neglect concerns, unsafe living conditions, or lack of needed services
Report suspected abuse, neglect, exploitation, or unsafe conditions according to mandated reporting requirements and agency policy
Escalate urgent or significant clinical concerns appropriately
Provide health education to participants and caregivers within the RN scope of practice
Requirements
Current and active Registered Nurse license in the State of California for at least 1 year
Minimum of 1 year of nursing experience
Strong nursing assessment and clinical judgment skills
Strong documentation, communication, and follow-up skills
Ability to work independently in a remote setting
Proficiency with electronic medical records, email, phone communication, and telehealth platforms
Knowledge of HIPAA, patient confidentiality, mandated reporting, and professional nursing standards
Ability to conduct nursing assessments remotely by phone or video
Ability to identify changes in condition and safety concerns through participant interview and care coordination
Strong verbal and written communication skills
Strong organizational and time management skills
Ability to manage assigned visits and documentation deadlines independently
Ability to communicate professionally with participants, families, caregivers, facilities, and providers
Ability to escalate concerns appropriately and timely
Ability to maintain privacy and confidentiality while working remotely
Comfort using computers, electronic documentation systems, telehealth platforms, and secure communication tools
Nice to have:
Experience with older adults, individuals with disabilities, assisted living, long-term care, home health, hospice, case management, or community-based programs
Experience conducting telehealth visits
Knowledge of ALW, CCT, HCBS, Medi-Cal waiver programs, or care coordination
Important Details
Willing to work onsite at McKinley, Taguig
Schedule: US Hours (Night shift)
About the Company
This company operates programs such as the Assisted Living Waiver (ALW) and California Community Transitions (CCT).
