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

Geriatric Nurse Specialist (LPN/RN) – Primary Care & Care Coordination Boston, United States | Posted on 07/06/2026 Make a Meaningful Difference in the Lives of OlderAdults The Staff Pad has partnered with a highly respected,physician-led healthcare organization that is transforming the way primary careis delivered to older adults across Massachusetts and New Hampshire. We are seeking a compassionate, experienced, andpatient-focused Geriatric Nurse Specialist (LPN or RN) who is passionate aboutimproving the health, independence, and quality of life of seniors. This is a uniqueopportunity to work alongside an interdisciplinary team dedicated to deliveringpersonalized, value-based care to Medicare beneficiaries across a variety ofcare settings. If you enjoy building lasting relationships withpatients, coordinating comprehensive care, and making a measurable impact onyour community, we'd love to hear from you. Schedule: Full-Time About the Role As a Geriatric Nurse Specialist, you'll play a vitalrole in supporting approximately 1,600 Medicare patients, including many olderadults with complex medical and social needs. Nearly one-third of our patientsare dual-eligible for Medicare and Medicaid, requiring thoughtful carecoordination and advocacy. You'll provide care and support across multiplesettings, including: Independentsenior living communities Assistedliving communities Skillednursing facilities Working closely with physicians, advanced practiceproviders, caregivers, and community partners, you'll help ensure every patientreceives exceptional, coordinated, person-centered care. What You'll Do Clinical Care & Preventive Services Preparefor and support Medicare Annual Wellness Visits by reviewing patientcharts, identifying preventive care gaps, completing required screeningassessments, and ensuring accurate Medicare documentation Coordinatepatient follow-up care by arranging recommended preventive services,referrals, and ongoing care based on screening and wellness visit findings Improvequality outcomes through preventive care initiatives Coordinatebreast and colorectal cancer screenings Promoteand track age-appropriate immunizations, including influenza, COVID-19,pneumococcal, shingles, RSV, and other recommended vaccines Conducthealthy aging assessments, including osteoporosis, cognitive impairment,dementia, fall risk, functional mobility, and home safety evaluations Providepatient education and support for cardiovascular risk reduction andadvance care planning Conductcomprehensive geriatric assessments evaluating functional status,ADLs/IADLs, cognitive health, mood, mobility, nutrition, medicationsafety, caregiver support, and social determinants of health Developindividualized care recommendations and collaborate with theinterdisciplinary team to guide patient care plans Facilitateadvance care planning discussions with patients and families, includingeducation on Advance Directives, Healthcare Proxies, and MOLST/POLSTdocumentation Collaboratewith providers on goals-of-care conversations and ensure accurate,complete documentation in the medical record Performcomprehensive medication reconciliation during Annual Wellness Visits,home and facility visits, transitional care, and follow-up appointments,identifying discrepancies and potential drug interactions Educatepatients and caregivers on medication purpose, administration, sideeffects, adherence, and safe use of high-risk medications commonlyprescribed to older adults Care Coordination & Community-Based Care Provideongoing care coordination for high-risk older adults, including recentlydischarged patients, individuals with multiple chronic conditions, frailseniors, dual-eligible Medicare/Medicaid beneficiaries, and patients withdementia, cognitive impairment, or frequent hospitalizations Collaboratewith physicians, specialists, home health agencies, rehabilitationproviders, hospitals, caregivers, and community organizations to ensureseamless transitions of care and improved patient outcomes Conducthome visits for homebound, recently hospitalized, medically complex, andfunctionally limited patients Assesshome safety, mobility, functional status, medications, caregiver needs,and unmet medical or social needs while connecting patients withappropriate community resources Collaboratewith staff across independent living communities, assisted livingfacilities, and skilled nursing facilities to coordinate patient care Supportquality improvement initiatives, monitor high-risk residents, assist withcare transitions, and serve as a clinical resource for facility staff What We're Looking For Required Qualifications LicensedPractical Nurse (LPN) or Registered Nurse (RN) Currentunrestricted MA license and the ability to obtain or maintain NH licensure 10+years of experience caring for geriatric patients Strongclinical knowledge of chronic disease management, medicationreconciliation, care transitions, and patient education for older adults Excellentcommunication skills with the ability to work independently andcollaborate effectively within an interdisciplinary team Validdriver's license and reliable transportation Preferred Qualifications GerontologicalNursing Certification Experiencewith Medicare Annual Wellness Visits, care management, home-based primarycare, and serving Medicare and Medicaid populations Experienceworking in assisted living, skilled nursing, or other senior livingsettings Familiaritywith Athenahealth EHR Knowledgeof Medicare quality initiatives, value-based care, ACO REACH, MSSP, APCM,and Chronic Care Management programs Key Qualifications & Physical Requirements Demonstratecompassion, empathy, strong clinical judgment, and excellent communicationand organizational skills Abilityto collaborate effectively while building trusted relationships withpatients, families, and healthcare partners Passionfor preventive, patient-centered care and improving the health,independence, and quality of life of older adults Abilityto travel between physician offices, patient homes, and senior livingcommunities Abilityto lift up to 25 pounds and safely walk, stand, bend, navigate residentialenvironments, and perform home safety assessments in a variety of settings Why Join This Team? This is more than a nursing position—it's anopportunity to build meaningful relationships with patients while helpingreshape the future of senior healthcare. You'll work alongside a dedicated interdisciplinaryteam that values collaboration, innovation, and compassionate care. Every day,you'll have the opportunity to help older adults remain healthier, safer, moreindependent, and connected to the care they deserve. If you're passionate about geriatrics and committed todelivering exceptional patient-centered care, we'd love to connect with you. #J-18808-Ljbffr The Staff Pad