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

Make a Meaningful Difference in the Lives of Older
Adults

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

About the Role

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
  
• 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.

What You'll Do

Clinical Care & Preventive Services

• 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
  

Care Coordination & Community -Based Care

• 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
  

What We're Looking For

Required Qualifications

• 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
  

Preferred Qualifications

• 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
  

Key Qualifications & Physical Requirements

• 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
  

Why Join This Team?

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.

If you're passionate about geriatrics and committed to
delivering exceptional patient -centered care, we'd love to connect with you.