RN Case Manager - Eau Claire

Department:
Care Coordination

Location:

Remote with travel throughout assigned service area

Reports To:

Care Coordination Supervisor

Sequoia Integrative Medical Services is seeking a compassionate, organized, and patient-focused Registered Nurse (RN) to join our Care Coordination team. The Case Manager RN plays a vital role in coordinating care for patients across the healthcare continuum, ensuring they receive the resources, education, and support needed to achieve optimal health outcomes.

This position works collaboratively with providers, facilities, patients, families, and community partners to improve continuity of care, reduce hospitalizations, and promote patient independence. The ideal candidate is an experienced nurse with strong critical thinking skills, exceptional communication abilities, and a passion for improving the lives of geriatric and medically complex patients.

• Conduct comprehensive patient assessments, including medical history, psychosocial needs, functional status, and barriers to care.
• Develop individualized, patient-centered care plans in collaboration with providers, patients, caregivers, and interdisciplinary team members.
• Coordinate services including home health, rehabilitation, specialty referrals, durable medical equipment (DME), hospice, and community resources.
• Facilitate smooth transitions of care following hospitalizations, emergency department visits, skilled nursing stays, or rehabilitation admissions.
• Monitor patients with chronic and complex medical conditions to promote improved health outcomes and prevent avoidable hospitalizations.

• Serve as a patient advocate by identifying and addressing barriers to care, including transportation, financial concerns, medication access, and social determinants of health.
• Connect patients and families with appropriate community resources and support services.
• Assist patients in navigating the healthcare system and coordinating follow-up appointments.

• Complete timely follow-up calls after hospital discharge and significant healthcare events.
• Monitor patient progress toward established goals and adjust care plans as clinical needs change.
• Collaborate with providers regarding changes in patient condition and recommend appropriate interventions.

• Partner with physicians, nurse practitioners, nurses, therapists, social workers, facility staff, and other healthcare professionals to coordinate comprehensive patient care.
• Participate in interdisciplinary case conferences and quality improvement initiatives.
• Communicate effectively with patients, caregivers, healthcare facilities, and community organizations.

• Educate patients and caregivers regarding diagnoses, medications, treatment plans, disease management, and preventive care.
• Encourage self-management strategies that improve quality of life and support long-term health goals.
• Provide education regarding available healthcare and community resources.

• Maintain accurate, timely, and complete documentation within the Electronic Health Record (EHR).
• Ensure compliance with HIPAA, Medicare regulations, organizational policies, and applicable state and federal requirements.
• Assist with quality initiatives and performance improvement projects.

• Maintain current nursing licensure and required certifications.
• Participate in continuing education and ongoing professional development.
• Stay current with evidence-based practices in case management and care coordination.

• Associate or bachelor's degree in nursing (BSN preferred)
• Current unrestricted Wisconsin Registered Nurse (RN) license
• Case Management Certification (CCM, ACM, or equivalent) preferred but not required

• Minimum one year of Registered Nurse experience required
• Previous experience in case management, care coordination, discharge planning, home health, hospice, primary care, geriatrics, or chronic disease management preferred
• Experience utilizing Electronic Health Record (EHR) systems
• Knowledge of Medicare, managed care, and community resources preferred

• Strong clinical assessment and critical thinking skills
• Excellent organizational and time management abilities
• Ability to prioritize multiple patients and changing clinical needs
• Exceptional communication and interpersonal…