NP - Home and Geriatric Care Coordination

MeasuredWellness; San Diego (CA); Hybrid; USD 120,000 - 160,000; Full time

Benefits offered by this job

Flexible schedule

Growth opportunities

Supportive team

Job summary

Measured Wellness seeks a Nurse Practitioner to specialize in geriatric care coordination, delivering in-home and virtual care to patients transitioning from hospital stays or managing complex chronic conditions in SNF or home health settings.

The NP will serve as the central clinical contact within SNF environments, overseeing comprehensive medical plans, coordinating with physical therapy, and ensuring safe, data-driven wellness for seniors through flexible scheduling and telehealth support.

Qualifications

• Experience working with geriatric patients or in SNF/home health settings.
• Strong communication across clinical teams and PCPs.
• Ability to manage multiple high-priority cases independently.
• Comfort delivering in-home and telehealth visits.

Responsibilities

• Oversee SNF patient care and monitor medical status and rehab progress.
• Coordinate Home Health PT integration with medical plans and meds.
• Communicate with PTs, SNF nursing staff, and PCP to align goals.
• Conduct initial and ongoing assessments; develop collaborative care plans.
• Monitor progress and adjust care plans or medications as needed.
• Oversee medication administration to avoid adverse effects during PT and mobility goals.
• Maintain timely communication with PCP regarding condition changes and post-SNF follow-up.
• Provide in-home and telehealth visits as needed for follow-ups and monitoring.

Skills

Geriatric care

SNF care knowledge

Interdisciplinary communication

Independent work

Telehealth familiarity

Flexible scheduling

Care coordination

Job description

Role and responsibilities

Nurse Practitioner (NP): Skilled Nursing and Home Health Care Coordinator

Measured Wellness, is seeking an exceptional Nurse Practitioner (NP) to specialize in geriatric care coordination, providing both in-home and virtual care services. This critical role ensures continuity and quality of care for patients transitioning from hospital stays or managing complex chronic conditions, particularly those receiving services in a Skilled Nursing Facility (SNF) or Home Health setting.

This position offers the unique opportunity to leverage technology for holistic, data-driven wellness while maintaining the essential human connection of geriatric care.

Key Role: Geriatric Care Coordination

The NP serves as the central point of clinical contact for the patient and their multidisciplinary team within the Skilled Nursing Facility (SNF) environment. This coordination is essential for patients receiving Home Health Physical Therapy who require oversight of their comprehensive medical and recovery plan.

Primary Focus Areas:

• SNF Care Oversight: Ensuring the patient’s overall medical monitoring, assistance with daily activities, and rehabilitation progress are integrated and aligned.
• Home Health PT Integration: Closely monitoring physical therapy (PT) to ensure therapeutic goals are safely integrated with the patient's medical status and medication regimen.
• Central Communication: Coordinating communication between the physical therapist, SNF nursing staff, and the patient's primary care provider (PCP).
• Comprehensive Assessment: Conduct detailed initial and ongoing assessments to identify the patient’s clinical status, functional limitations, and specific therapy goals.
• Collaborative Care Plan Development: Partner directly with the Physical Therapist to establish a personalized, realistic therapy plan that considers the patient’s current health needs and recovery potential.
• Progress Monitoring & Adjustment: Routinely review patient rehabilitation progress (PT updates and milestones) and make necessary, proactive adjustments to the overall care plan or medication regimen.
• Medication Management: Actively oversee medication administration to ensure accuracy and identify and mitigate any potential side effects that could negatively impact the patient's physical therapy sessions or mobility goals.
• PCP Communication: Maintain consistent and timely communication with the patient’s Primary Care Physician (PCP) regarding progress, acute changes in condition, and coordination of post-SNF follow-up care.
• In-Home and Virtual Visits: Provide necessary clinical care through flexible scheduling, utilizing both in-person, in-home visits (where needed) and virtual telehealth sessions for check-ins and monitoring.

Qualifications

• Demonstrated experience or strong preference for working with the geriatric population and managing complex chronic conditions.
• Experience with or strong knowledge of Skilled Nursing Facility (SNF) care, home health protocols, and physical therapy integration is highly desirable.
• Excellent communication skills, both clinical and interdisciplinary.
• Ability to work independently and manage multiple, high-priority patient cases.
• Flexible Schedule: Enjoy flexible work hours that can be scheduled around your availability, supporting work-life balance.
• Growth Opportunity: Opportunity to grow with a forward-thinking, patient-centered practice that integrates technology and data for superior outcomes.
• Supportive Team: Access to a supportive and collaborative team environment.
• Compensation: Competitive compensation package.
• Equal Opportunity Employer: We are an equal opportunity employer and welcome applications from all qualified individuals. We value diversity and are committed to creating an inclusive environment for all employees.
• Join our team and make a difference in patients' lives by providing exceptional telehealth care focused on holistic, data-driven wellness and effective chronic care management.