Description

You will coordinate comprehensive care for frail elderly PACE participants, working with an interdisciplinary team to ensure optimal health outcomes and quality of life. This includes care transitions, assessments, care planning, and advocacy.

Requirements

• Valid and active RN license

Responsibilities

• Collaborate with interdisciplinary team to coordinate care across settings
• Facilitate timely discharge planning and follow-up care after hospitalizations
• Perform home care assessments and create care plans
• Provide education to participants, caregivers, and families
• Complete utilization management activities