Geriatric Care RN - Home Visits & Care Coordination

PACE; Milford (DE); On-site; USD 85,000 - 105,000; Full time

Benefits offered by this job

Medical

Dental

Vision

401K

PTO + 6 paid Holidays

Job summary

PACE Your LIFE is seeking a Registered Nurse (RN) to join the Interdisciplinary Team for full-time, in-home care coordination in Delaware. The role emphasizes proactive health management, caregiver coaching, and seamless care transitions across settings.

You will work closely with IDT members, primary care, home care, and external partners to deliver person-centered care that aligns with PACE standards and regulatory requirements.

Qualifications

• Graduate of an accredited school of professional nursing.
• Active Delaware RN license.
• 2+ years nursing experience, preferably in geriatric, home care, or care management.
• Experience with chronic disease management and interdisciplinary collaboration.
• Strong communication and engagement skills; proficient with EMR, Outlook, Word, and Excel.

Responsibilities

• Conduct ongoing health assessments, wellness checks, and chronic disease monitoring.
• Coordinate care across primary, specialty, hospital, SNF, and home settings; ensure timely follow-ups.
• Provide disease education, safety guidance, and support caregiver education.
• Participate in daily IDT meetings and document assessments and outcomes in the EMR.
• Perform home visits and support center-based nursing operations as needed.
• Adhere to CMS guidelines, regulatory requirements, and infection control standards.

Skills

Home health care

Interdisciplinary teamwork

Care coordination

HIPAA compliance

Communication skills

Education

Active Delaware RN license

Tools

Electronic Health Records (EMR)

Job description

PACE Your LIFE is seeking a Registered Nurse (RN) to join the Interdisciplinary Team for full-time, in-home care coordination in Delaware. The role emphasizes proactive health management, caregiver coaching, and seamless care transitions across settings.

You will work closely with IDT members, primary care, home care, and external partners to deliver person-centered care that aligns with PACE standards and regulatory requirements.