Estimated Start Date: 11/30/2026
Role Scope: The RN Care Manager delivers personalized, longitudinal nursing care to a panel of PACE participants, conducting face-to-face assessments across physical, psychosocial, and behavioral domains in both center and home settings, and partnering with medical providers to implement care plans. This role manages care coordination end-to-end, collaborating and coordinating with the entire care team as needed. As a collaborative participant and leader in Interdisciplinary Team (IDT) meetings, this role contributes clinical insights that inform whole-person care planning and educates participants, caregivers, and team members on carrying out personalized care plans - all while contributing to a center culture grounded in Habitat's values and participant belonging
Core Responsibilities & Expectations for the Role- Contribute to a center experience that Participants want to spend time in, a team culture that cares and creates joy, and an environment where all participants and team members belong.
- Continue to raise the bar. Constructively seek and share feedback and help us implement changes in order to improve clinical outcomes and experience for participants.
- Exhibit and honor Habitat's Values.
- Participate n Interdisciplinary Team (IDT) meetings by contributing insights from assessments, care plan recommendations, and care coordination in a collaborative spirit.
- 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 escalate 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.
- Option to participate in after-hour calls that are triaged on a rotating schedule for extra compensation.
- Perform related duties as assigned.
Required Qualifications: - Graduate of an accredited school of nursing or equivalent experience.
- Unencumbered California Registered Nurse (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 healthy debate and 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.
Nice to have: - Bachelor's of Science (BSN) preferred.
- PACE experience and/ or ADCH/CBAS experience.
- A state issued driver's license, personal transportation, and auto insurance as required by law.
- Bilingual Spanish/English or Cantonese/English preferred, other language abilities are also a plus
Essential Functions & Physical Requirements The following statements describe the general nature of work and physical expectations common across roles at Habitat Health. Specific responsibilities may vary by position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Team members in this role may be expected to:
- Work in healthcare, administrative, community, or remote environments, depending on role needs.
- Communicate effectively with participants, caregivers, team members, and other stakeholders in person, by phone, and through electronic systems.
- Remain stationary and/or move about for extended periods, consistent with job duties.
- Operate standard office equipment and/or clinical tools (e.g., computers, phones, medical devices, documentation systems).
- Travel between work sites or community locations as needed.
- Follow safety procedures, infection control protocols, and use personal protective equipment (PPE) when required.
- Perform tasks that may involve bending, reaching, lifting, or assisting participants, depending on role responsibilities.
- Lift, carry, push, or pull supplies, equipment, or materials typically up to 25-50 pounds, with assistance or mechanical aids, depending on job duties and role responsibilities.
Compensation: The anticipated base salary range for this position is
$58.00 - $68.00 per hour. This position is also eligible for a target annual bonus of
5% of the annual salary and may be eligible for additional incentive compensation, as applicable.
The final compensation offered will be determined based on factors including, but not limited to, the candidate's qualifications, skills, experience, education, certifications, geographical location, and business needs.
In addition, this position is eligible for a comprehensive benefits package, including medical, dental, and vision insurance; paid parental leave, short- and long-term disability coverage; life insurance; flexible spending accounts; a 401(k) savings plan that includes a match; paid time off; and company paid holiday
