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.

• Provide primary care and acute illness evaluation and treatment for participants in collaboration with PACE Physicians and Community-Based PACE Physicians.
• In collaboration with a physician, perform in-person comprehensive assessments (initial, semi-annual and unscheduled) on participants and coordinate with the IDT to develop a comprehensive care plan for each participant.
• Collaborate with physician(s) and IDT in discharge planning from acute or long-term care settings.
• In consultation with the PACE Physician and/or Community-Based PACE Physician, refer participants to medical specialists as indicated.
• In collaboration with the PACE Physician and/or Community-Based PACE Physician, manage care of participants in the nursing home, making regular visits as dictated by Seen Health standards and participant need.
• Be an active member of the IDT communicating participant changes, collaborating on care planning decisions and coordinating 24-hour care delivery.
• Work collaboratively with PACE Physicians, Community-Based PACE Physicians and other members of the IDT to ensure effective care coordination.
• Participate in rotating night and weekend call.
• At the direction of the Medical Director, review outcomes and utilization data, including review of necessity of hospitalizations and use of specialists; establish best practices with the Medical Director, and collaborate with clinical staff, PACE Physicians, Community-Based PACE Physicians and IDT to make policy and procedural improvements to reduce unnecessary utilization and improve participant health.
• Be legally authorized to practice in position location, required.
• Only act within the scope of his or her authority to practice.
• Complete all required documentation in a timely and accurate manner.
• Protect privacy and maintain confidentiality of all company procedures and information about team members, participants, and families.
• Follow Seen Health policies and procedures and participate in any required Quality Improvement activities, staff training and meetings.
• Communicate regularly with Supervisor and team regarding workload and priorities.
• Timely completion of all mandated trainings and education.
• Timely completion of all mandated occupational health screenings as needed.
• Exercises flexibility in performing assignments as business needs evolve.
• Other duties as assigned.

Qualifications

Education/Training/Certifications:

• Graduate of an Accredited School of Nursing
• RN State License.
• Certification as a Nurse Practitioner with Prescriptive Authority.
• Valid State Driver’s License with a clean DMV record.
• Copy of recent Vehicle Insurance required.
• Proficiency in Mandarin and/or Cantonese preferred.

Skills and Experience:

• Minimum of two years’ nursing experience in a clinical setting with a frail or elderly population.
• Ability to build strong working relationships with other providers and care team.
• Creative and enthusiastic commitment to improving experience, health, and value for PACE participants.
• Current knowledge of chronic care/geriatric issues and best practices.
• Work well in a managed care environment with an interdisciplinary team (IDT).
• Excellent clinical, organizational, and communication skills in settings with frail, elderly participants, their families, and the IDT.
• Working knowledge of PACE regulations preferred.
• Excellent organizational and communication skills.
• Ability to work independently with minimal supervision.
• Demonstrated ability to prioritize in a fast-paced environment.
• Experience and competency working with people from diverse backgrounds and cultures.