RN Care Manager — In-Home & Center PACE

Habitat-Health; San Leandro (CA); On-site; USD 166,194,000 - 194,848,000; Full time

Job summary

Habitat Health seeks an RN Care Manager in California to deliver personalized, longitudinal nursing care to a PACE participant panel. You will conduct face-to-face assessments in center and home settings and partner with medical providers to implement care plans.

You will manage care coordination end‑to‑end, lead IDT discussions, document nursing interventions, and support transitions of care and complex discharges as part of a collaborative care team.

Qualifications

• Graduate of an accredited school of nursing or equivalent experience.
• Unencumbered California RN license required.
• Minimum 2-4 years of experience clinically caring for medically complex or older adults’ population as an RN.
• Minimum 1-2 year's 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 current CPR/BLS certification required or requirement to obtain within 30 days of employment.
• A minimum of one year experience working with the frail or elderly.
• Aligns with our purpose and our values, and is excited about living those out in daily practice.
• Ability to thrive in a fast‑paced, evolving environment with comfort navigating ambiguity, adapting quickly, and contributing to continuous improvement.
• Strong learning and growth mindset, including seeking feedback, engaging in healthydebateand using data and curiosity to inform decisions.
• Acts with integrity and ownership, considering the broader organizational impact, doing the right thing, and following through to deliver results.

Responsibilities

• 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 as needed.
• 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 escalation 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.
• Optiontoparticipateinafter-hour calls that are triaged on a rotating schedulefor extra compensation.
• Perform related duties as assigned.

Skills

Nursing

Care coordination

Wound care

IV therapy

Phlebotomy

CPR/BLS

Communication

Bilingual Spanish/English

Education

RN license

BSN preferred

Tools

EMR systems

Clinical documentation

Job description

Habitat Health seeks an RN Care Manager in California to deliver personalized, longitudinal nursing care to a PACE participant panel. You will conduct face-to-face assessments in center and home settings and partner with medical providers to implement care plans.

You will manage care coordination end‑to‑end, lead IDT discussions, document nursing interventions, and support transitions of care and complex discharges as part of a collaborative care team.