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Job Summary: The Registered Nurse (RN) is a full-time licensed registered nurse embedded within the PACE Your LIFE Interdisciplinary Team (IDT). The PHN provides longitudinal, relationship-based nursing, focusing on proactive health management, early identification of changes in condition, participant and caregiver coaching, and coordination across care settings. This role strengthens continuity, supports chronic disease management, and enhances participant engagement to promote safe aging in place.

The Registered Nurse (RN) works collaboratively with the IDT, primary care providers, home care, therapy, social work, and external partners to ensure participants receive comprehensive, person-centered care aligned with PACE regulatory requirements.  

 Shift Type:

• Full - Time

Benefits:

• Medical

• Dental

• Vision

• 401K

• PTO + 6 paid Holidays

Essential Duties and Responsibilities:

Participant Health Management

·       Conduct ongoing health assessments, wellness check-ins, and chronic disease monitoring.

·       Identify early changes in condition and initiate timely interventions.

·       Develop individualized health action plans in collaboration with the IDT.

Care Coordination & Transitions

·       Coordinate care across primary care, specialty care, hospital, SNF, and home settings.

·       Support participants during transitions of care, ensuring medication reconciliation, follow-up appointments, and caregiver education.

·       Communicate proactively with external providers and community partners.

·       Serve as the individual’s consistent, accessible health partner and advocate.

Participant & Caregiver Coaching

·       Provide education on disease processes, medications, self-management, and safety.

·       Support healthy literacy and shared decision-making.

·       Reinforce adherence to care plans and preventive care recommendations.

Interdisciplinary Team Integration

·       Participant in daily IDT meetings, care planning, and case reviews.

·       Document assessments, interventions, and outcomes in the EMR in accordance with PACE standards.

·       Collaborate with IDT members to ensure seamless coverage and continuity of care and services.

Home & Center-Based Support

·       Conduct home visits as needed for assessment, coaching, and follow-up.

·       Support center-based nursing operations during peak needs or participant changes in condition.

Quality, Compliance, and Safety

·       Adhere to all PACE regulatory requirements, CMS guidelines, and organizational policies.

·       Participate in QI initiatives, audits, and performance improvement activities.

·       Maintain infection control standards and promote participant safety.

Knowledge and Skills:

·       Comfortability with providing care to participants within their home

·       Knowledge of medical terminology

·       Ability to undertake a variety of diverse care tasks and work in an interdisciplinary team

·       Compliance with all HIPAA policies and regulations

·       Compassionate and able to handle stress

Qualifications:

        1.        Education:

a.     Graduate of an accredited school of professional nursing

        2.        Credentials/Licensure Required:

a.     Current active license as a Registered Nurse in Delaware

        3.        Experience:

a.     Two years professional nursing experience required. Long-term care and/or home health care experience preferred

b.     Minimum 2-3 years of nursing experience, preferably in geriatric, home care, care management, community health, or hospice.

c.      Experience with chronic disease management and interdisciplinary collaboration.

d.     Strong communication and engagement skills, and interdisciplinary collaboration.

e.     Proficient use of Electronic Health Records, Outlook, Word, and Excel preferred

        4.        Age of Patients Rendered Care:

a.     Adult and geriatric patients

        5.        Core Competencies

a.     Participant-centered care

b.     Clinical judgement and early change detection

c.      Care coordination and systems navigation

d.     Health coaching and education

e.     Team collaboration

f.       Regulatory compliance and documentation accuracy

        6.         Other requirements:

a.     Ability to travel between participant homes, the PACE center, and external facilities.

b.     Work is performed in clinical, home, and community settings.

*** Freedom from illegal use of drugs, and freedom from use and effects of use of drugs    and alcohol in the workplace.

*** Persons who have been found guilty by a court of law of abusing, neglecting or mistreating individuals in a healthcare-related setting are ineligible for employment in this position.