RN Care Manager

About this role

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.

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 r

Similar jobs

• RN Care Manager — Summit Health · Atlanta, GA
• RN Care Manager — Corewell Health · Grand Rapids, MI
• RN Care Coordinator — Corewell Health · Royal Oak, MI
• RN Care Coordinator — Stph · Covington, LA
• RN Care Coordinator — Chapters Health System · Okeechobee, FL
• RN Care Coordinator — Corewell Health · Farmington Hills, MI
• RN Care Coordinator — Corewell Health · Dearborn, MI