- Coordinate comprehensive care for older adults enrolled in the Program of All-Inclusive Care for the Elderly (PACE)
- Develop, implement, and monitor individualized care plans that promote independence and reduce unnecessary hospitalizations
- Conduct participant assessments and coordinate services across medical, behavioral health, therapy, and community resources
- Serve as the primary nursing case manager while collaborating with physicians, nurse practitioners, therapists, social workers, and additional interdisciplinary team members
- Maintain continuity of care through ongoing participant follow-up, education, and care coordination
- Complete timely documentation utilizing the electronic medical record system
Requirements
- Active Registered Nurse (RN) license in Massachusetts
- Minimum two years of Registered Nurse experience
- Home health, case management, community health, or geriatric nursing experience preferred
- Strong assessment, care coordination, and communication skills
- Ability to work independently while collaborating within an interdisciplinary team
- Valid driver's license and reliable transportation for community visits
- Electronic medical record experience preferred
Core Competencies
Demonstrates expertise in coordinating comprehensive care for older adults, including developing and monitoring individualized care plans, conducting assessments, and ensuring continuity of care through effective communication and collaboration with interdisciplinary teams.
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