RN Care Manager

Overview

Habitat Health empowers older adults to experience more good days in their homes and communities. Through the Program of All-Inclusive Care for the Elderly (PACE), we provide comprehensive medical care along with support for daily needs such as meals, transportation, and in‑home assistance. We deliver coordinated clinical and social care in our centers and directly in participants’ homes, creating a fully integrated experience that brings peace of mind and a true sense of belonging.

As we expand our scalable, affordable PACE model to meet the growing and complex needs of aging populations, our mission‑driven care teams continue to help participants live well on their own terms.

In this role, you will be responsible for the management and delivery of direct nursing care to our participants in a variety of settings including, but not limited to, the clinic, adult day center, participant’s home, virtually, and SNF. You will serve as a critical member of the Interdisciplinary Team (IDT) and work 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 in 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 that are inclusive of physical, psychosocial, and behavioral statuses in various settings, primarily in 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 responding to physician orders, and correctly administering medications and therapeutic interventions.
• Provide case management longitudinally and 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, which includes independently initiating therapies within scope of practice and collaboratively working with a medical provider to elevate care as needed.
• Educate participants, caregivers including family members, and team members on how to personalize and carry out care plans.
• Aid with all wound care (including complex wounds), IV (hydration, therapies), and any additional procedures within RN scope of practice identified to meet evolving participant needs.
• Delegate tasks to MA and Licensed Vocational Nurses within their respective scopes of practice.
• Remotely take 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 experience clinically caring for a complex or older adults’ population as an RN.
• Minimum 1‑2 years of experience in case management.
• Strong clinical acumen in chronic disease management and complex geriatric care.
• Demonstrates experience in management of 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 are up to date.
• Proof of current CPR/BLS certification required or requirement to obtain within 30 days of employment.
• Proof of valid CA driver’s license, personal transportation, good driving record and auto insurance as required by State law.