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

The Staff Pad•Boston, MA

18d•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. Schedule: Full-Time. As a Geriatric Nurse Specialist, you'll play a vital role in supporting approximately 1,600 Medicare patients, including many older adults with complex medical and social needs. Nearly one-third of our patients are dual-eligible for Medicare and Medicaid, requiring thoughtful care coordination and advocacy. You'll provide care and support across multiple settings, including primary care practices, patient homes, independent senior living communities, assisted living communities, and skilled nursing facilities. Working closely with physicians, advanced practice providers, caregivers, and community partners, you'll help ensure every patient receives exceptional, coordinated, person-centered care.

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.