Registered Nurse Case Manager-HCH Senior Care

Location Address: 2925 Chicago Ave Loading Dock Minneapolis, MN

Date Posted: December 29, 2025

Department:  Senior Care Transitions Complex Care

Shift: Day (United States of America)

Shift Length: 8 hour shift

Hours Per Week: 40

Union

Contract:

Non-Union-NCT

Weekend Rotation: None

Allina Health is a not-for-profit health system that cares for individuals, families and communities throughout Minnesota and western Wisconsin. If you value putting patients first, consider a career at Allina Health. Our mission is to provide exceptional care as we prevent illness, restore health and provide comfort to all who entrust us with their care. This includes you and your loved ones.

We are committed to providing whole person care, investing in your well-being, and enriching your career.

• 1.0 FTE (80 hours per two-week pay period)
• 8-hour day shifts
• No weekends

Nursing is the assessment and treatment of human response to actual or potential health problems. This includes establishing an intentional therapeutic relationship between a registered nurse and a patient and family. As a leader and the integrator of care, the professional nurse has the responsibility, authority, and accountability for planning, coordinating and evaluating the patient’s care needs.

Provides proactive, comprehensive care coordination for high-risk geriatric patients to improve outcomes, enhance quality of life, and reduce unnecessary healthcare use. Independently manages a complex patient panel, leading interdisciplinary care planning to support patient function and access to services. Advocates for patients facing complex health issues through a person-centered, team-based approach.

Serves as a clinical resource, using nursing judgment and communication skills to assess patient needs, guide care decisions, and support diagnosis-based outcomes. Assists the care team in triaging and addressing acute and chronic concerns for complex patients.

• Assessment and Plan
  • Conducts holistic assessments through chart review and direct interaction, addressing clinical, emotional, psychosocial, social needs and barriers, and functional barriers.
  • Coordinates transitional care to reduce readmissions and support smooth discharges, including advance care planning and hospice transitions when appropriate.
  • Identifies risk factors and recommends interventions for complex conditions (e.g., heart failure, diabetes, COPD, dementia) and chronic needs.
  • Develops person-centered care plans aligned with clinical goals.
  • Uses data and risk tools to identify high utilizers and implement targeted interventions.
  • Monitors quality metrics and adjusts care plans accordingly.
  • Applies evidence-based practice and regulatory standards in care planning.
• Outcomes Identification
  • Identifies expected outcomes individualized to the patient.
  • Establishes, in collaboration with the patient and caregiver, realistic and measurable patient expected outcomes based on nursing diagnoses, patient’s current and potential capabilities, goals, available resources and plan for continuity of care.
• Implementation
  • Implements interventions outlined in plan of care in a safe, timely, appropriate manner.
  • Works with participants, caregivers and providers to resolve identified barriers and coordinate needed services.
  • Utilizes motivational interviewing skills to facilitate and engage participants toward behavioral changes through exploration and resolving ambivalence.
  • Facilitates communication between participant, caregivers and all members of the health care team, including referral facilitation to completion.
  • Documents interventions according to documentation guidelines.
  • Follows the participant over time, across continuum of care to measure effectiveness of the plan, modifying as necessary to accommodate changes for optimal health.
  • Collaborates with team to respond to acute and chronic needs of patient panel including hands on care (vital signs, wound assessments, modifying environment to fit care needs, administer vaccines, etc.).
• Evaluation and Professional Oversight
  • Continuously evaluates patient and caregiver understanding, engagement, and outcomes related…