Nurse Practitioner - PACE

Blue Ridge Care; Winchester (VA); On-site; USD 90,000 - 120,000; Full time

Job summary

Blue Ridge Care is seeking a Nurse Practitioner to join its PACE program, delivering comprehensive primary care to frail older adults in a team-based setting.

The Nurse Practitioner will perform assessments, manage ongoing care, and coordinate with the interdisciplinary team to optimize outcomes and maintain independence for participants in the community.

Qualifications

• Graduate of an accredited School of Nursing.
• Current RN license and NP certification.
• Active NP license and national certification.
• CPR/BLS certification.
• Valid driver's license and reliable transportation.

Responsibilities

• Conduct comprehensive history and physical assessments for new PACE participants.
• Perform semi-annual and as-needed reassessments and update care plans.
• Evaluate, diagnose, and treat acute illnesses and changes in participant condition.
• Develop and implement individualized care plans with the IDT.
• Coordinate referrals to specialists and other providers as needed.
• Provide education and health coaching to participants, caregivers, and families.
• Ensure accurate clinical documentation and coding.

Skills

Geriatric assessment

Interdisciplinary teamwork

Communication skills

Clinical decision making

EHR proficiency

Education

RN license

NP program graduate

NP license

National NP certification

CPR/BLS certification

Job description

Nurse Practitioner - PACE Program

At Blue Ridge Care, we deliver extraordinary care to improve life's journey. As a mission-driven, not-for-profit healthcare system, we provide integrated services in hospice, serious illness care, the Program of All-Inclusive Care for the Elderly (PACE), community thrift shops, and grief support. Our goal is simple: to reimagine how communities experience aging, serious illness, and end-of-life care through compassionate, personalized, high-quality care.

We are seeking a dedicated Nurse Practitioner (NP) to join our PACE team and provide comprehensive, participant-centered primary care to frail older adults. This role offers the opportunity to work collaboratively within an interdisciplinary team while helping participants maintain independence, improve quality of life, and remain safely in their communities.

Position Summary

Under the supervision of the Medical Director, the Nurse Practitioner provides primary care services to PACE participants, including comprehensive assessments, ongoing evaluations, diagnosis and treatment of acute and chronic conditions, participant education, and care coordination. The Nurse Practitioner serves as an active member of the Interdisciplinary Team (IDT) and plays a key role in developing and implementing individualized plans of care for medically complex older adults.

What You'll Do

Clinical Care & Participant Management

• Conduct comprehensive history and physical assessments for new PACE participants.

• Perform semi-annual and as-needed reassessments and update care plans accordingly.

• Evaluate, diagnose, and treat acute illnesses and changes in participant condition.

• Develop and implement individualized care plans in collaboration with the IDT.

• Coordinate referrals to specialists and other healthcare providers as needed.

• Provide education and health coaching to participants, caregivers, and families.

• Coordinate participant care across healthcare settings and community providers.

• Ensure accurate, timely clinical documentation and diagnostic coding.

Interdisciplinary Collaboration

• Participate actively in Interdisciplinary Team meetings.

• Provide clinical recommendations and support coordinated care planning.

• Serve as a geriatric care resource for team members.

• Collaborate with physicians and other healthcare professionals to support participant outcomes.

Quality & Compliance

• Support quality improvement initiatives and best-practice standards.

• Review records and documentation to ensure regulatory compliance.

• Educate staff regarding the specialized needs of frail older adults.

• Adhere to PACE regulations, organizational policies, and professional standards.

• Maintain participant confidentiality and uphold all safety and infection prevention guidelines.

On-Call Responsibilities

• Participate in an established on-call rotation.

• Provide clinical guidance and support during evenings, weekends, and holidays as assigned.

• Respond appropriately to after-hours participant needs and coordinate escalation of care when necessary.

What We're Looking For

Education & Licensure

• Graduate of an accredited School of Nursing.

• Current Registered Nurse (RN) license.

• Graduate of an accredited Nurse Practitioner program.

• Current Nurse Practitioner license.

• National Nurse Practitioner certification.

• Current CPR/BLS certification.

• Valid driver's license, reliable transportation, and proof of insurance.

Preferred Qualifications

• Geriatric Nurse Practitioner (GNP) certification with prescriptive authority.

• Experience working in a PACE program or integrated care model.

• Knowledge of PACE regulations and geriatric care best practices.

Experience

• Minimum of two (2) years working with frail elderly or medically complex adult populations.

• Two (2) years of Nurse Practitioner experience in geriatrics or a related specialty strongly preferred.

• Experience in home-based care, long-term care, community-based services, or multidisciplinary healthcare settings preferred.

Skills & Competencies

• Strong geriatric assessment and clinical decision-making skills.

• Excellent communication and interpersonal abilities.

• Ability to build meaningful relationships with older adults and caregivers.

• Strong organizational and time-management skills.

• Ability to work effectively within an interdisciplinary team.

• Experience using electronic health records (EHR) and clinical documentation systems.

• Ability to manage competing priorities in a dynamic healthcare environment.

Physical Requirements

• Ability to stand, walk, bend, reach, push, and pull throughout the workday.

• Ability to lift and carry up to 50 pounds.

• Ability to push or pull equipment exceeding 150 pounds using proper body mechanics.

• Ability to work with medically complex and cognitively impaired populations.

• Strong observation, communication, and critical thinking abilities.

Why Join Blue Ridge Care?

Mission-driven, not-for-profit organization dedicated to serving our community
Collaborative and supportive interdisciplinary team environment
Opportunity to make a direct impact on the lives of older adults
Meaningful work that promotes dignity, independence, and quality of life
Ongoing professional development and continuing education opportunities