Registered Nurse; RN - Case Management

Job Title and Location

RN Case Manager – Glenwood, Illinois.

Chen Med is seeking a Registered Nurse (RN) for Case Management duties. The RN Case Manager is responsible for achieving positive patient outcomes and managing quality of care across the continuum of care. The incumbent serves as an advocate for patients, collaborating with care teams to develop effective plans of care and ensuring coordination across settings including centers, acute and post‑acute facilities, and home environments.

• Manages and plans transitions of care, discharge and post‑discharge follow‑up for patients admitted to high‑volume or high‑priority hospitals.
• Establishes trusting relationships with patients and their caregivers.
• Collaborates with clinical staff in developing and executing plans of care and achieving goals.
• Reports variations to PCP/Transitional Care Physicians and implements appropriate actions.
• Builds relationships with preferred acute care providers and directs referrals.
• Coordinates integration of social services/case management functions in pre‑acute, ER, acute, and post‑acute settings.
• Coordinates patient, discharge, and home planning processes with hospital case management and other facilities.
• Uses e‑mail, DASH, HITS or other communication means to keep PCP informed of patient conditions.
• Introduces self to patient/family, explains Nurse Case Manager role and processes for contact.
• Provides high‑intensity engagement with patient and family, facilitates conferences to review goals, and optimizes resource utilization.
• Serves as a patient advocate, enhances collaborative relationships, and supports informed decisions.
• Addresses advanced care planning, treatment goals, and advance directives.
• Refers cases to a social worker for complex psychosocial or economic needs.
• Reports suspected child or adult abuse per mandated requirements.
• Obtains onsite and EMR access at priority facilities.
• Maintains clinical and progress notes, submits documentation timely in the computer system.
• Participates in surveys, studies, and special projects as assigned.
• Conducts concurrent medical record review using specific indicators and criteria.
• Investigates and reports adverse occurrences, performs staff education related to resource utilization and discharge planning.
• Promotes effective utilization of clinical resources and mobilizes resources to achieve outcomes within time frames.
• Evaluates patient satisfaction and quality of care.
• Communicates with physicians regularly throughout hospitalization, developing effective working relationships.
• Assists physicians to maintain appropriate cost, case, and desired patient outcomes.
• Coordinates the provision of social services to patients, families, and significant others.
• Completes expanded assessment of patient and family needs at admission, including psychosocial assessment.
• Participates in development and implementation of patient care policies and protocols.
• Attends meetings as assigned and performs other duties as assigned by the manager.

• Identifies appropriateness of inpatient vs. observation status.
• Identifies and manages safety risk, functional status (ADLs, PT needs), medication management, knowledge deficits, and implements the ACM Coaching program.
• Facilitates discharge to appropriate level of care and preferred providers.
• Communicates discharge information to all stakeholders and coordinates follow‑up PCP appointments.
• Discusses patient eligibility for CCM or DM programs and identifies interest.
• Coordinates acute UR physician meetings.

• Provides telephonic or outpatient visits to high‑risk patients to prevent ER visits or admissions.
• Performs clinical functions including disease assessment, medication monitoring, health education, and self‑care instructions.
• Coordinates the Plan of Care, makes recommendations, and ensures plan implementation.
• Assesses environment of care, caregiver capacity, patient and caregiver educational needs.
• Coordinates, reports, documents, and follows up on HPP/IDT meetings and super huddles.
• Helps patients navigate health systems and connects them…