RN Case Management
Core
Coordinate comprehensive medical and social care for frail seniors with complex health needs, ensuring safe transitions and dignified aging-in-place.
Role type
Senior Registered Nurse Case Manager (Geriatric)
Builds
Integrated PACE care programs and home-based service delivery for underserved older adults
Domain
Healthcare / Elderly Care / PACE Model
Required skills
Care coordination, discharge planning, home health assessment, utilization management, palliative care, wound care, medication administration, regulatory compliance, data analytics for care outcomes
Preferred skills
Mandarin or Cantonese proficiency, geriatric care experience, influential communication with families
Technologies
Electronic Health Record (EHR) systems
Responsibilities
Coordinate interdisciplinary team (IDT) care across clinic, hospital, and home settings; design and update individualized care plans; facilitate timely hospital-to-home transitions; conduct home care assessments and delegate services; manage utilization of hospital admissions and specialist consultations; provide end-of-life and palliative support; document outcomes and maintain medical records.
Seniority
Senior, hands-on IC