Geriatric Nurse Specialist (LPN/RN) – Primary Care & Care Coordination

The Staff Pad • Boston, MA

38d • Hybrid

About The Position

The Staff Pad has partnered with a highly respected, physician-led healthcare organization that is transforming the way primary care is delivered to older adults across Massachusetts and New Hampshire. We are seeking a compassionate, experienced, and patient-focused Geriatric Nurse Specialist (LPN or RN) who is passionate about improving the health, independence, and quality of life of seniors. This is a unique opportunity to work alongside an interdisciplinary team dedicated to delivering personalized, value-based care to Medicare beneficiaries across a variety of care settings. If you enjoy building lasting relationships with patients, coordinating comprehensive care, and making a measurable impact on your community, we'd love to hear from you.

Requirements

• Licensed Practical Nurse (LPN) or Registered Nurse (RN)
• Current unrestricted MA license and the ability to obtain or maintain NH licensure
• 10+ years of experience caring for geriatric patients
• Strong clinical knowledge of chronic disease management, medication reconciliation, care transitions, and patient education for older adults
• Excellent communication skills with the ability to work independently and collaborate effectively within an interdisciplinary team
• Valid driver's license and reliable transportation
• Demonstrate compassion, empathy, strong clinical judgment, and excellent communication and organizational skills
• Ability to collaborate effectively while building trusted relationships with patients, families, and healthcare partners
• Passion for preventive, patient-centered care and improving the health, independence, and quality of life of older adults
• Ability to travel between physician offices, patient homes, and senior living communities
• Ability to lift up to 25 pounds and safely walk, stand, bend, navigate residential environments, and perform home safety assessments in a variety of settings

Nice To Haves

• Gerontological Nursing Certification
• Experience with Medicare Annual Wellness Visits, care management, home-based primary care, and serving Medicare and Medicaid populations
• Experience working in assisted living, skilled nursing, or other senior living settings
• Familiarity with Athenahealth EHR
• Knowledge of Medicare quality initiatives, value-based care, ACO REACH, MSSP, APCM, and Chronic Care Management programs

Responsibilities

• Prepare for and support Medicare Annual Wellness Visits by reviewing patient charts, identifying preventive care gaps, completing required screening assessments, and ensuring accurate Medicare documentation
• Coordinate patient follow-up care by arranging recommended preventive services, referrals, and ongoing care based on screening and wellness visit findings
• Improve quality outcomes through preventive care initiatives
• Coordinate breast and colorectal cancer screenings
• Promote and track age-appropriate immunizations, including influenza, COVID-19, pneumococcal, shingles, RSV, and other recommended vaccines
• Conduct healthy aging assessments, including osteoporosis, cognitive impairment, dementia, fall risk, functional mobility, and home safety evaluations
• Provide patient education and support for cardiovascular risk reduction and advance care planning
• Conduct comprehensive geriatric assessments evaluating functional status, ADLs/IADLs, cognitive health, mood, mobility, nutrition, medication safety, caregiver support, and social determinants of health
• Develop individualized care recommendations and collaborate with the interdisciplinary team to guide patient care plans
• Facilitate advance care planning discussions with patients and families, including education on Advance Directives, Healthcare Proxies, and MOLST/POLST documentation
• Collaborate with providers on goals-of-care conversations and ensure accurate, complete documentation in the medical record
• Perform comprehensive medication reconciliation during Annual Wellness Visits, home and facility visits, transitional care, and follow-up appointments, identifying discrepancies and potential drug interactions
• Educate patients and caregivers on medication purpose, administration, side effects, adherence, and safe use of high-risk medications commonly prescribed to older adults
• Provide ongoing care coordination for high-risk older adults, including recently discharged patients, individuals with multiple chronic conditions, frail seniors, dual-eligible Medicare/Medicaid beneficiaries, and patients with dementia, cognitive impairment, or frequent hospitalizations
• Collaborate with physicians, specialists, home health agencies, rehabilitation providers, hospitals, caregivers, and community organizations to ensure seamless transitions of care and improved patient outcomes
• Conduct home visits for homebound, recently hospitalized, medically complex, and functionally limited patients
• Assess home safety, mobility, functional status, medications, caregiver needs, and unmet medical or social needs while connecting patients with appropriate community resources
• Collaborate with staff across independent living communities, assisted living facilities, and skilled nursing facilities to coordinate patient care
• Support quality improvement initiatives, monitor high-risk residents, assist with care transitions, and serve as a clinical resource for facility staff

Benefits

• This is more than a nursing position—it's an opportunity to build meaningful relationships with patients while helping reshape the future of senior healthcare.
• You'll work alongside a dedicated interdisciplinary team that values collaboration, innovation, and compassionate care.
• Every day, you'll have the opportunity to help older adults remain healthier, safer, more independent, and connected to the care they deserve.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed