Case Manager

Role Summary

The Case Manager is a vital member of the Interdisciplinary Care Team and collaborates with the team to deliver and manage all aspects of participant care. This role involves conducting required assessments, developing individualized Care Plans, and addressing patient needs. The Case Manager communicates with participants and their families, advocates for participant needs, and works in partnership with the Primary Care Provider to deliver care in various settings, including centers, homes, skilled nursing facilities, or other care settings.

• Take ownership of the outcomes and quality of care for assigned participants, working directly with the Primary Care Provider and utilizing clinic resources.
• Conduct in-clinic, at-home, and virtual assessments, educate participants and their support network on health conditions, and perform follow-up visits based on participant needs.
• Develop and implement a discipline-specific plan of care in collaboration with the interdisciplinary team, participants, and families to ensure high-quality, participant-centric care.
• Identify participant needs, prioritize them, and collaborate effectively with team members to address these needs.
• Coordinate care for participants with complex needs, ensuring seamless transitions of care and preventing unnecessary hospitalizations.
• Collaborate with the Primary Care Provider to manage clinical tasks, follow up on test results, and ensure timely communication with participants.
• Perform and document procedures and care in clinic or at home as necessary, following the scope of practice and provider directives.
• Communicate participant changes to the interdisciplinary team and coordinate discharges and transitions of care.
• Review medical test results and collaborate with providers on timely participant responses, ensuring appropriate documentation and follow-up.
• Support clinic operations in the absence of supervisory roles, as needed, to ensure the delivery and coordination of participant care.
• Act as a coordinator of care on behalf of participants, evaluating and following up on patient care measures.

• Minimum of two years of nursing experience in a clinical setting with a frail or elderly population.
• Knowledge and skills necessary to treat frail, elderly participants and manage complex clinical situations.
• Highly motivated, self-directed, and able to make sound decisions in emergency situations.
• Excellent clinical, organizational, and communication skills in settings with seniors, their families, and interdisciplinary team members.
• Ability to multitask and contribute to projects, activities, timelines, and process improvement initiatives.
• Ability to work independently with minimal supervision and prioritize in a fast-paced environment.
• Experience and competency working with people from diverse backgrounds and cultures.
• Commitment to unlocking the full potential of vulnerable seniors.

• Bilingual in English/Spanish is preferred.

This is a 13-week assignment, Monday to Friday, 8:00 AM to 4:30 PM, with potential travel 2-5 times per week in the immediate surrounding area. The candidate will work closely with a nurse practitioner and an interdisciplinary team on a daily basis.