PNW PACE Care Coordination RN

Conduct initial nursing assessments for new PACE enrollments and perform semi-annual or change of condition assessments as directed by the IDT. Coordinate clinical discharge planning and medication reconciliation with the Social Work Department while serving as the primary RN contact in hospitals, SNFs, and post-acute facilities. Lead bedside representation across home, hospital, clinic, and post-acute settings to ensure safe, timely transitions of care. Communicate clinical changes to RNCMs and provide structured handoffs at transition completion to promote continuity. This role functions as a key liaison between hospital teams, PACE IDT members, and community providers within MultiCare's Pacific Northwest health system.