Registered Nurse Care Coordinator

Senior Care Partners C.E.•Kalamazoo, MI

About The Position

Senior Care Partners PACE provides coordinated preventive, primary, acute, and long-term care services to older adults so they can continue living in the community. The Registered Nurse Care Coordinator (RNCC) works with participants, families, caregivers, and an interdisciplinary team to coordinate personalized, participant-centered care, manage chronic conditions, support care transitions, and promote independence and quality of life. The role includes in-home assessments, medication safety support, hands-on nursing care, coordination of equipment and services, and collaboration with healthcare and community partners. The RNCC also supports participants and families through end-of-life care and advance care planning, maintains timely documentation, completes required education, and meets regulatory and organizational requirements.

Requirements

Nursing diploma or degree from an accredited school of nursing or university.
Current Registered Nurse (RN) licensure in the State of Michigan.
At least one year of experience working with frail older adults or in a long-term care setting.
At least one year of home care experience.
Must be fully vaccinated or willing to become vaccinated against influenza, MMR, varicella, Tdap/Td, COVID-19, and hepatitis B.
Must meet CMS competency standards before working independently.
Must be willing to work beyond normal hours.
Must be comfortable working in varied home environments and all-weather conditions.

Responsibilities

Develop, implement, and update individualized care plans with participants, families, caregivers, and the interdisciplinary team.
Advocate for participant preferences, autonomy, dignity, and quality of life while helping navigate healthcare needs.
Conduct in-home assessments of health status, medication and educational needs, and resources needed for safety at home.
Provide disease-specific education, develop action plans, and implement strategies to manage chronic conditions and prevent complications and hospitalizations.
Conduct in-home medication reviews, assist with medication setup, identify adherence barriers, and educate participants and caregivers on safe medication use.
Coordinate hospital discharges and transitions of care with transition team members and external providers.
Perform focused nursing and skin assessments, immunizations, medication administration, and laboratory specimen collection as needed.
Coordinate medical equipment, oxygen, incontinence supplies, personal emergency response systems, and other services.
Participate in end-of-life services, educate families about expected changes and medications, and facilitate family meetings and advance care planning conversations.
Collaborate with hospitals, skilled nursing facilities, adult foster care providers, hospice teams, provider offices, vendors, and community partners.
Complete timely documentation, required education, and regulatory and organizational requirements, and keep leadership informed of emerging concerns.