Registered Nurse; R.N.) Geriatric Case Manager - Home Care

Position: Registered Nurse (R.N.) Geriatric Case Manager - Home Care (Full-Time, Days)
Location: City of Rochester

Job Title:

Geriatric Case Manager Department:
Homecare

Location:

Rochester Regional Health Home Care
- Monroe Avenue

Schedule:

Monday
- Friday, 8:30am to 4:30pmRochester Regional Health Home Care is the only home care provider in the region to earn a CMS 5-Star Quality of Patient Care rating, placing its CHHA among the top 3.5% of agencies nationwide. In addition, CHHA was recognized by U.S. News & World Report as a “High Performing Home Care Agency,” further highlighting its commitment to exceptional patient care and clinical excellence.

SUMMARY:

The role is responsible for the delivery of comprehensive nursing care to a set of assigned patients thru the RRH Geriatric Service Verification program. This involves the pre-surgical assessment of eligible patients in the GSV program. The RN will work with the patient, family, Geriatric APP team to recognize post discharge needs and the development, implementation and evaluation of an appropriate Plan of Care.

The incumbent will make changes in response to evaluation & assessment of patient needs. The role identifies appropriate interdisciplinary services needed, coordinates those services and supervises the delivery of care.

RESPONSIBILITIES:

Conducts Comprehensive Assessments of older adults’ physical, emotional, cognitive, and social needs, including pre-surgical in-home evaluations and post-discharge follow-up, with a focus on identifying and addressing Social Determinants of Health.

Develops and Implements Interdisciplinary Care Plans in collaboration with patients, caregivers, and healthcare teams to support recovery and independence in the least restrictive setting.

Coordinates and Monitors Care by navigating health systems, ensuring timely services, tracking patient progress, and adjusting care plans as needed to meet individual goals.

Responds to Health Crises and Advocates for Patients, addressing emergencies like hospitalizations and ensuring high-quality, patient-centered care aligned with individual preferences.

Provides Leadership and Quality Oversight, including supervising care teams, mentoring new staff, documenting thoroughly, participating in quality improvement, and supporting program growth.

REQUIRED QUALIFICATIONS:

Associates Degree in NursingA minimum of 2 years of nursing experience in home care, geriatric care or case management

Registered Nurse license in New York State Valid NYS Driver’s License PREFERRED ATTRIBUTES:

Master’s in Nursing:
Healthcare Leadership or Geriatric NPGeriatric nurse case managers will work in various settings, including hospitals and patient homes. They need strong communication, organizational, and problem-solving skills to effectively support their clients

Consistently demonstrates high standards of integrity by supporting the Rochester Regional Health Companies’ mission and values and adhering to the Corporate Code of Conduct

EDUCATION:

LICENSES /

CERTIFICATIONS:

PHYSICAL REQUIREMENTS:

Drive
- Clinical
- Roles in this category require frequent driving combined with mobile clinical care across settings such as emergency response, mobile clinics, and home health environments. Staff must repeatedly enter and exit vehicles, occasionally lift and carry equipment weighing up to 100 lbs. or more, and perform care within patients’ homes or other confined, unpredictable, or uncontrolled environments. These positions demand strong fine and gross motor control, firm grasping, and heightened visual and auditory awareness to ensure safe and effective care delivery.

Emotional and cognitive demands are substantial due to rapid decision‑making, direct exposure to critical or sensitive situations, and independently managing patient care in the field or home setting. Environmental exposures may include traffic hazards,…