Location: Sacramento, Open to out of state candidates- relocation bonus provided

Position: Full-time

Earn a $5,000 Bonus! $2,500 after 90-day training completion + $2,500 at 6 months.

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 Nur