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Salary: USD 116,480 - 143,520 / annual
Habitat Health is a healthcare organization delivering comprehensive care to older adults through the Program of All-Inclusive Care for the Elderly (PACE). The company provides integrated clinical and social care in centers and participants' homes, supported by leading investors including Kaiser Permanente and New Enterprise Associates.
The RN Care Manager delivers personalized, longitudinal nursing care to a panel of PACE participants. This role conducts face-to-face assessments across physical, psychosocial, and behavioral domains in both center and home settings, partnering with medical providers to implement individualized care plans. The Care Manager manages care coordination end-to-end, collaborating with the entire care team and serving as a clinical leader in Interdisciplinary Team (IDT) meetings where they contribute insights that inform whole-person care planning.
Key responsibilities include:
- Conducting comprehensive nursing assessments in various settings (primarily center-based, with in-home visits as needed)
- Delivering personalized care for an assigned panel of participants based on established care plans
- Documenting nursing interventions, responding promptly to physician orders, and administering medications and therapeutic interventions
- Providing longitudinal case management and coordinating complex patient discharges, transfers, and post-discharge needs with hospital and long-term care facility case managers
- Coordinating all aspects of care delivery including medication management, medical equipment and supplies, and specialist and diagnostic referrals
- Triaging in the outpatient setting, independently initiating therapies within scope of practice and collaboratively escalating care as needed
- Participating actively in IDT meetings and educating participants, caregivers, and team members on personalized care plans
- Contributing to a center culture grounded in Habitat's values and participant belonging
- Seeking and sharing constructive feedback to improve clinical outcomes and participant experience
The role requires lifting, carrying, pushing, or pulling supplies and equipment up to 25–50 pounds, with assistance or mechanical aids as needed. Start date is November 30, 2026.
Qualifications:
- Current RN licensure required
- Experience in nursing care management, preferably in geriatric or PACE settings
- Strong clinical assessment and documentation skills
- Ability to work collaboratively in interdisciplinary team environments
- Excellent communication skills with participants, families, and care team members
- Ability to manage complex care coordination and transitions of care
- Physical ability to conduct in-home visits and lift/carry materials up to 50 pounds with assistance
