RN Care Manager; PACE

At Habitat Health, we envision a world where older adults experience an independent and joyful aging journey in the comfort of their homes, enabled by access to comprehensive health care. Habitat Health provides personalized, coordinated clinical and social care as well as health plan coverage through the Program of All-Inclusive Care for the Elderly (PACE) in collaboration with our leading healthcare partners, including Kaiser Permanente.

Habitat Health offers a fully integrated experience that brings more good days and a sense of belonging to participants and their caregivers. We build engaged, fulfilled care teams to deliver personalized care in our centers and in the home, while supporting our partners with scalable solutions to meet the health care needs and costs of aging populations.

Habitat Health is growing, and we’re looking for new team members to join our mission of redefining aging in place.

Note:
This role is scheduled to start on 8/10/26.

In this role, you will be responsible for the management and delivery of direct nursing care to participants in a variety of settings, including the clinic, adult day center, participant’s home, virtually, and SNF. You will serve as a critical member of the Interdisciplinary Team (IDT), working collaboratively to complete assessments and drive forward participant care plans as a “quarterback” for your panel.

• Contribute to a center experience that participants want to spend time in, a team culture that cares and creates joy, and an environment where all participants and team members belong.
• Continue to raise the bar; constructively seek and share feedback and help us implement changes to improve clinical outcomes and experience for participants.
• Exhibit and honor Habitat’s values.
• Participate and facilitate Interdisciplinary Team (IDT) meetings by contributing insights from assessments, care plan recommendations, and care coordination in a collaborative spirit.
• Conduct face-to-face nursing assessments inclusive of physical, psychosocial, and behavioral statuses in various settings, primarily at the Habitat center but also in home.
• In partnership with a medical provider, deliver personalized care for a panel of participants based on care plans.
• Deliver and document nursing interventions as agreed upon in participant's care plans, promptly and accurately respond to physician orders, and correctly administer medications and therapeutic interventions.
• Provide longitudinal case management and care during transitions of care; proactively coordinate complex patient discharges, transfers, and immediate post-discharge needs with hospital and long-term care facility case managers.
• Coordinate all aspects of care delivery including medication management, medical equipment and supplies, and specialist and diagnostic referrals.
• Triage in the outpatient setting, independently initiating therapies within scope of practice and collaborating with a medical provider to raise care as needed.
• Educate participants, caregivers, and team members on how to personalize and carry out care plans.
• Aid with wound care (including complex wounds), IV (hydration, therapies), and any additional procedures within RN scope of practice.
• Delegate tasks to MA and Licensed Vocational Nurses within their respective scopes.
• Remotely handle after-hour calls that are triaged on a rotating schedule.
• Perform related duties as assigned.

• Graduate of an accredited school of nursing;
  Bachelor of Science (BSN) preferred.
• Unencumbered Registered Nurse (RN) license required.
• Minimum 2-4 years of clinical experience caring for formally complex or older adults’ populations as an RN.
• Minimum 1-2 years of experience in case management.
• Strong clinical acumen in chronic disease management and complex geriatric care.
• Demonstrated experience managing clinical interventions: wound care, IVs, phlebotomy, colostomy/ileostomy care, etc.
• Proof of medical clearance for communicable diseases, including a TB test.
• Proof of all immunizations up to date.
• Proof of current CPR/BLS certification, or requirement to obtain within 30 days of employment.
• Proof of valid…