Home Care Team RN, PACE Geriatric Care
Overview
You will own clinical care coordination for a caseload of frail elders in west Brooklyn, keeping them safe at home through PACE interdisciplinary teamwork. You will partner with RNs, social workers, and therapists to deliver 1st shift weekday care with no holidays. You will drive member outcomes through assessments, care planning, and home visits. This role stands apart with its Monday-Friday schedule and focus on community-based geriatric care.
What You'll Do8
- 1Conduct initial and ongoing assessments of frail elders in their homes, documenting vital signs, medication reviews, and functional status.
- 2Build individualized care plans with the interdisciplinary team, updating them at 90-day intervals or on status changes.
- 3Deliver skilled nursing interventions including wound care, medication management, and chronic disease monitoring.
- 4Coordinate PACE center services by scheduling primary care visits, specialty referrals, and transportation for members.
- 5Lead care conferences with families and caregivers, translating complex medical plans into actionable home routines.
- 6Drive hospital readmission prevention by managing transitional care and post-discharge follow-up within 48 hours.
- 7Document all encounters in electronic health records within 24 hours, ensuring CMS compliance and quality metrics.
- 8Mentor home health aides through hands-on training and supervision during joint visits.
Requirements9
- 1Current RN license in New York State is required.
- 23+ years of nursing experience with a focus on geriatric or home care.
- 31+ year working with frail elderly or chronic disease populations.
- 4Valid driver's license and reliable car with proof of insurance.
- 5BLS certification required; ACLS preferred.
- 62+ years using electronic health records for documentation.
- 7Strong written and verbal communication skills for family education.
- 8Ability to lift 50 pounds for transfer assistance during home visits.
- 9Background check and physical required prior to hire.
Salary Insight
$73 - $79k per year
Location
Required Skills
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