Care Manager, RN

Habitat Health empowers older adults to experience more good days in their homes and communities. Through the Program of All-Inclusive Care for the Elderly (PACE), we provide comprehensive medical care along with support for daily needs such as meals, transportation, and in ‑ home assistance. We deliver coordinated clinical and social care in our centers and directly in participants’ homes, creating a fully integrated experience that brings peace of mind and a true sense of belonging. As we expand our scalable, affordable PACE model to meet the growing and complex needs of aging populations, our mission ‑ driven care teams continue to help participants live well on their own terms. Habitat Health is supported by leading healthcare organizations and investors including New Enterprise Associates, Kaiser Permanente, and Town Hall Ventures. We are entering a period of significant growth and are looking for exceptional teammates to help us scale a better model of care for older adults. To learn more, visit www.habitathealth.com. 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 need…