Registered Nurse Care Coordinator

Senior Care Partners PACE; Portage (MI); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Medical, Dental, Vision Insurance

Paid Holidays

PTO and Sick Time

403(b) Retirement Savings

Life insurance

Employee Assistance

Job summary

Senior Care Partners PACE is seeking an experienced Registered Nurse Care Coordinator to join our interdisciplinary team and coordinate personalized care for participants living in the community.

You will work closely with physicians, nurse practitioners, social workers, and other professionals to manage chronic conditions, support transitions of care, and empower participants to remain independent with dignity and safety at home.

Qualifications

• Nursing diploma or degree from an accredited school.
• Current RN licensure in the State of Michigan.
• At least 1 year of experience with frail older adults or in long‑term care.
• At least 1 year of home care experience.

Responsibilities

• Coordinate personalized care plans with participants, families, and the interdisciplinary team.
• Advocate for participant preferences, autonomy, dignity, and quality of life.
• Conduct in‑home assessments and identify care and educational needs.
• Manage chronic conditions with disease‑specific education and action plans.
• Support medication safety and educate participants and caregivers on proper use.
• Coordinate transitions of care with hospitals, SNFs, and other providers.
• Provide focused nursing assessments, immunizations, and specimen collection as needed.
• Connect participants with essential resources and equipment.
• Support families through care stages and participate in advance care planning.

Skills

Nursing

Care coordination

Home care

Education

Nursing diploma/degree

Job description

The Program of All-Inclusive Care for the Elderly (PACE) offers a variety of services, with many of them provided onsite at a PACE Center.

PACE is an alternative to nursing home care and – through an interdisciplinary care team (IDT) of physicians, nurse practitioners, nurses, social workers, therapists, van drivers, and aides – coordinates and provides preventive, primary, acute, and long-term care services, so older individuals can continue living in the community.

Why You’ll Love it Here

• Purpose
• Professional Development
• Paid Holidays
• PTO and Sick Time
• Internal opportunities for growth
• Team Support
• Competitive Pay
• Medical, Dental, Vision Insurance
• Life insurance
• 403(b) Retirement Savings
• Employee Assistance
• And MORE!

Make a Difference. Empower Independence. Transform Lives.

Join Senior Care Partners PACE and help older adults live safely, confidently, and with dignity.

Are you a compassionate Registered Nurse who thrives on building relationships, solving complex clinical challenges, and helping people achieve their best possible quality of life? At Senior Care Partners PACE, you can put your nursing expertise to work in a meaningful, participant-centered role that goes beyond traditional bedside care.

Working closely with an interdisciplinary team (IDT), you will coordinate personalized care, manage chronic conditions, support transitions between care settings, and empower participants to remain as independent as possible.

If you are passionate about holistic care, collaborative teamwork, and making a lasting impact in the lives of older adults, we invite you to join our team!

As a Registered Nurse Care Coordinator (RNCC), you will be a trusted advocate, clinical resource, and care partner for participants and their families.

What You’ll Do

As an RN Care Coordinator, you will play a vital role in ensuring participants receive the right care, at the right time, in the right setting.

• Coordinate Personalized Care: Develop, implement, and update individualized care plans in partnership with participants, families, caregivers, and the interdisciplinary team.
• Champion Participant Well-Being: Advocate for participant preferences, autonomy, dignity, and quality of life while helping navigate complex healthcare needs.
• Conduct In-Home Assessments: Evaluate health status, identify medication and educational needs, and help ensure participants have the resources necessary to remain safe at home.
• Manage Chronic Conditions: Provide disease-specific education, develop action plans, and implement strategies to prevent avoidable complications and hospitalizations.
• Support Medication Safety: Conduct in-home medication reviews, assist with medication setup, identify barriers to adherence, and educate participants and caregivers on safe medication use.
• Coordinate Transitions of Care: Collaborate with transition team members and external providers to support hospital discharges, care transitions, and continuity of services.
• Provide Hands-On Nursing Care: Perform focused nursing assessments, skin assessments, immunizations, medication administration, and laboratory specimen collection as needed.
• Connect Participants With Essential Resources: Coordinate medical equipment, oxygen, incontinence supplies, personal emergency response systems, and other necessary services.
• Support Participants and Families Through Every Stage of Care: Participate in end-of-life services, educate families about expected changes and medications, and facilitate family meetings and advance care planning conversations.
• Build Strong Care Partnerships: Collaborate with hospitals, skilled nursing facilities, adult foster care providers, hospice teams, provider offices, vendors, and other community partners.
• Maintain Excellence in Clinical Practice: Complete timely documentation, required education, and regulatory and organizational requirements while keeping leadership informed of emerging concerns.

What Makes You a Great Fit?

You are a skilled, independent nurse who combines sound clinical judgment with empathy, communication, and a genuine commitment to person-centered care. You are comfortable managing complex situations, coordinating multiple services, and building trust with participants and their families.

Required Qualifications

• Nursing diploma or degree from an accredited school of nursing or university.
• Current Registered Nurse (RN) licensure in the State of Michigan.
• At least one year of experience working with frail older adults or in a long‑term care setting.
• At least one year of home care experience.

Why This Role Matters

At Senior Care Partners PACE, care coordination is about more than managing appointments and treatment plans. It is about seeing the whole person, understanding what matters most to them, and bringing people and services together to support their health, independence, and quality of life.

As an RN Care Coordinator, your clinical expertise and compassion can help prevent unnecessary hospitalizations, strengthen family support, improve health outcomes, and give participants greater confidence in their daily lives.

You will have the opportunity to use your nursing skills in a collaborative, interdisciplinary environment where your voice matters and your work makes a meaningful difference.

Additional Requirements

• Must be fully vaccinated or willing to become vaccinated against: Influenza, MMR, Varicella, Tdap/Td, COVID-19, and Hepatitis B
• Must meet CMS competency standards prior to working independently
• Must be willing to work beyond normal hours
• Comfortable working in varied home environments and all‑weather conditions

Join Us!

Senior Care Partners PACE is proud to be an Equal Employment Opportunity employer.