RN Case Manager

• Provide in-house, facility, telephonic, and home visits to high-risk patients to prevent unnecessary hospital admissions and readmissions
• Perform field nursing interventions, patient assessments, care-plan development, clinical assessments, fall-prevention assessments, social-determinants-of-health screenings, medication monitoring, health education, and self-care instruction
• Conduct initial case-management assessments, obtain patient consent, and coordinate individualized plans of care with patients, caregivers, PCPs, and care-team members
• Review charts and conduct final patient discharge; obtain formal approval from the Complex Care Leadership Team when required
• Conduct supervisory visits with LPNs and patients, providing education and overseeing appropriate discharge
• Coordinate multidisciplinary team meetings, report and document care activities, and follow up on action items
• Help patients navigate healthcare systems and connect them with community, social, and financial resources
• Coordinate service delivery, facilitate use of natural supports and community resources, and maintain communication with families and community providers
• Establish supportive relationships that promote patient self-management
• Monitor the quality, frequency, and appropriateness of HHA visits and other outpatient services
• Collaborate with Complex Care and Clinical Strategy Team members, including Hospital Care Managers and Post Hospital Care Coordinators and Managers, to ensure holistic care
• Provide urgent home visits under PCP direction to prevent unnecessary hospital admissions
• Provide clinical supervision and serve as a clinical lead for the Complex Care Team
• Perform other duties as assigned by the manager

• Associate degree in Nursing required
• Valid, active Registered Nurse (RN) license in the state of employment required
• Minimum 2 years of clinical work experience required
• Minimum 1 year of community case-management experience highly desired
• Bachelor's Degree in Nursing (BSN) or RN with a bachelor's degree in a related clinical field preferred
• Compact nursing license preferred where available
• Certified Case Manager certification through CCMC or CMCN desired/preferred
• Current, valid driver's license required and must be maintained
• Basic Life Support (BLS) certification from the American Heart Association or American Red Cross required within the first 90 days of employment
• Strong interpersonal and communication skills
• Critical-thinking skills
• Ability to work autonomously
• Ability to monitor, assess, and record patient progress and adjust plans accordingly
• Ability to plan, implement, and evaluate individual patient care plans
• Knowledge of nursing and case-management theory and practice
• Knowledge of patient-care charts and patient histories
• Knowledge of clinical and social-services documentation procedures and standards
• Knowledge of community health and social-services support agencies and networks
• Organizing and coordinating skills
• Ability to communicate technical information to non-technical personnel
• Proficiency in Microsoft Office Suite, including Excel, Word, PowerPoint, and Outlook
• Ability and willingness to travel locally, regionally, and nationwide up to 10% of the time
• Spoken and written fluency in English
• Independent judgment required

Demonstrates expertise in nursing and case management, with a focus on patient assessments, care plan development, and coordination of multidisciplinary care. Proficient in navigating healthcare systems and connecting patients with community resources while ensuring quality patient care.

• Registered Nurse (RN) License
• Clinical Work Experience
• Community Case Management Experience
• Certified Case Manager (CCM)
• Basic Life Support (BLS) Certification

• Patient Assessment
• Care Plan Development
• Clinical Supervision
• Medication Monitoring
• Fall Prevention Assessment
• Social Determinants of Health Screening
• Patient Progress Monitoring
• Documentation Procedures
• Community Health Knowledge
• Nursing Theory and Practice

• Interpersonal Skills
• Communication Skills
• Critical Thinking
• Organizing Skills
• Autonomous Work Ability

• Registered Nurse (RN) License
• Certified Case Manager (CCM)
• Basic Life Support (BLS) Certification

• Case Management
• Patient Care
• Healthcare Systems
• Community Resources
• Multidisciplinary Team Coordination

• Microsoft Office Suite
• Excel
• Word
• Power Point
• Outlook