Clinic RN

About the role

As a Clinic RN in our PACE program, you are a core member of our interdisciplinary team (IDT) and a central clinical presence in our Alhambra center. You bring the clinical expertise that ensures our participants - a frail and elderly population with complex, evolving needs - are thoroughly assessed, have care plans that reflect their current status, and receive attentive, high-quality care day to day. This role is grounded in direct clinical practice: conducting assessments, developing and maintaining care plans, managing chronic conditions, and delivering hands-on nursing care in the clinic. You will also be a vital voice in IDT, contributing clinical insight that shapes how the team cares for each participant. The right person for this role is clinically strong, attentive to detail, and motivated by the opportunity to build something meaningful in a setting that genuinely centers the communities it serves.

Responsibilities

• Clinical assessment & care planning
• Conduct comprehensive nursing assessments for new enrollees and ongoing participants, including functional, cognitive, and psychosocial evaluations.
• Develop, implement, and maintain individualized care plans in collaboration with the interdisciplinary team, ensuring they reflect participants' current health status, goals, and evolving needs.
• Monitor and manage chronic conditions - including diabetes, heart failure, COPD, and dementia - adjusting care plan interventions in coordination with PCPs as conditions change.
• Evaluate care plan effectiveness on an ongoing basis and initiate updates in response to changes in participant status, hospitalizations, or new clinical findings.
• Day-to-day clinic nursing
• Triage inbound communications - calls, faxes, messages from participants, families, and external partners - prioritizing clinical needs and coordinating responses accordingly.
• Conduct same-day urgent care visits and respond to acute clinical concerns presenting in the center, escalating to PCPs as appropriate.
• Administer medications, vaccinations, wound care, and other nursing interventions within RN scope of practice.
• Perform and review vitals monitoring, flagging abnormal findings and communicating with the care team in a timely manner.
• Support medication reconciliation processes, including following up on medication changes after hospitalizations or specialist visits.
• Manage post-appointment processes including diagnostic orders, lab coordination, medication management, and specialist referrals.
• Provide on-site clinical guidance and oversight to LVNs, PCAs, and CNAs as needed, under the direction of the Clinic Manager.
• Interdisciplinary team participation
• Participate as an active IDT member, contributing timely and accurate clinical updates on participant status and flagging concerns that require team discussion.
• Collaborate with the Care Manager, social workers, PCPs, and other IDT members to ensure care is coordinated across settings and that participants receive necessary medical, social, and supportive services.
• Provide participant and family education on care plans, chronic disease management, medication adherence, and preventive care strategies.
• Support care transitions, including post-hospitalization follow-up, in coordination with the Care Manager and PCP.
• Documentation & compliance
• Maintain thorough, accurate, and timely documentation in the electronic health record, including assessments, care plans, progress notes, and service records.
• Perform dut

Benefits

Additional Information

About Seen Health At Seen Health, we are revolutionizing the way senior care is delivered through the PACE (Programs of All-Inclusive Care for the Elderly) model. Backed by top VCs, Seen Health is a culturally-focused, technology-enabled healthcare organization that integrates comprehensive medical care and social support with a high-touch, interdisciplinary approach. Our mission is to empower seniors to age-in-place with dignity and provide their families peace of mind. We are building upon a proven Home and community based services model to create a culturally-competent and scalable PACE program. We are also building a comprehensive operating system focused on data and workflows that span across systems, processes, people, and care contexts. We want to empower our clinicians and staff with tools that deliver relevant data at the time and site of care and enable them to deliver exceptional care to our participants, which improve clinical outcomes, participant & provider satisfaction, and ultimately our strength as an organization. We are a mission-driven, multidisciplinary team with deep healthcare, technology, and operations expertise, each inspired by our own personal stories of caring for seniors in our lives. Our name, Seen Health, was chosen to reflect our commitment to provide the highest standard of care to underserved older adults while respecting and incorporating their individual beliefs, heritage, and values, so that they can truly be seen .

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