Elder Care Registered Nurse

Responsibilities

• Conduct comprehensive patient assessments via telephone, virtual visits, and in-home/community visits
• Develop, implement, and monitor individualized care plans for patients with multiple chronic conditions
• Provide disease-specific education and self-management support
• Deliver telephonic health coaching and chronic care management services
• Monitor patient status and identify changes requiring provider intervention
• Document accurately, timely, and thoroughly in the electronic medical record
• Participate in interdisciplinary team meetings and care planning discussions
• Coordinate care across providers, caregivers, and community resources
• Serve as a consistent point of contact for patients and families
• Assist with advance care planning conversations as appropriate
• Facilitate connections to community-based services during field visits
• Ensure compliance with CMS requirements for Chronic Care Management (CCM) and related programs
• Support quality improvement initiatives and workflow refinement
• Maintain working knowledge of chronic care management best practices
• Ensure compliance with organizational policies, HIPAA, and applicable regulations
• Support accurate documentation for billing and quality reporting

Qualifications

• Bachelor’s degree in Nursing (BSN)
• Current California RN license
• Experience in chronic care management and/or telehealth preferred
• Strong communication and interpersonal skills
• Ability to work independently and as part of a team
• Knowledge of geriatric care and chronic disease management

Skills

• Excellent clinical judgment and decision-making skills
• Effective problem-solving and critical thinking abilities
• Strong organizational and time management skills
• Proficiency in electronic medical records (EMR) systems
• Ability to work flexible hours and travel to various locations

Benefits

• Flexible scheduling
• Professional growth opportunities
• Positive team culture
• Employee Assistance Program
• Market-competitive pay

Pay

• $48.00 – $61.00 per hour

Schedule

• Part-time structure with variable scheduling based on census and patient needs
• Approximately up to 24 hours per week
• Hybrid role: Approximately 50% telephonic/virtual care and 50% field-based visits
• Schedule varies based on patient census and program needs