Registered Nurse Case Manager

TCI has an immediate need for a Home Health RN Case Manager in Williamsburg, VA . This is a contract-to-hire opportunity.


Note: This position requires US Citizenship and work is performed on-site.



SUMMARY


We are seeking a compassionate and organized Registered Nurse (RN) Case Manager to coordinate patient care, assess needs, develop individualized care plans, and collaborate with patients, families, providers, and interdisciplinary teams. The ideal candidate will have strong clinical judgment, communication, and care coordination skills, with a commitment to delivering high-quality, patient-centered outcomes.



RESPONSIBILITIES

• Perform comprehensive assessment of high-risk members.
• Collaborate with primary care providers to ensure the implementation of an individualized, comprehensive care plan with specific interventions designed to engage the member.
• Address, identify, and continuously reassess cost-efficient, appropriate levels of care.
• Put non-medical support in place to ensure compliance with treatment plans (such as housing and transportation).
• Coordinate care transitions as needed.
• Coordinate with physicians, social workers, discharge planners, and claims professionals in transitioning patient to appropriate level of care.
• Engage specialty resources as needed to achieve optimal resolution.
• Keep detailed records of clinical, functional, and fiscal outcomes during the management process.
• Identify opportunities for health promotion and illness prevention.
• Prevent adverse patient occurrences when possible and intervene quickly if prevention is not possible, thereby minimizing poor outcomes.
• Act as patient advocate by protecting privacy and confidentiality issues.

• Active, unrestricted RN license. Virginia License or Compact Licenses accepted.
• Case Management Certification.
• Associate or Bachelor's degree in Nursing.
• Hospice experience is a must and home care home base experience is a plus.
• Clinical nursing experience; case management experience preferred.
• Ability to analyze complex medical information and make rational decisions
• Strong assessment, care coordination, communication, and organizational skills.
• Ability to collaborate effectively with patients, families, providers, and interdisciplinary teams.
• Knowledge of care planning, documentation, and healthcare resources.
• Proficiency with electronic medical records and standard computer applications.
• Home Health care provided in counties of Williamsburg, Yorktown, Gloucester, Hampton Roads, Poquoson, and Charles City.
• Work schedule is 8am-5pm M-F; on-call rotation for weekends; milage reimbursement provided.