RN Care Manager - Hourly

RN Care Manager

Unicity Care Management is seeking an experienced, compassionate RN Care Manager to support older adults and their families as they navigate complex health, safety, and aging-related decisions at home and in senior communities. The Care Manager (RN) will manage a small private-pay caseload and provide comprehensive assessment, care coordination, nursing oversight, advocacy, and ongoing monitoring to ensure each client has the right services and supports in place.

This role is ideal for a Registered Nurse who loves being in the field, enjoys problem-solving, and wants to use clinical judgment in a holistic, relationship-based care management model rather than in a traditional bedside or facility-based role.

What you'll do (RN Care Manager)

• Manage a small caseload of private-pay clients as the primary RN point of contact for clients and families in their homes or in Independent Living, Assisted Living, or Nursing Facilities.
• Perform in-depth assessments, including medical, psychosocial, environmental, functional, legal, and family dynamics, to develop a complete picture of each client's health status and risks.
• Complete and interpret clinical screening tools such as Fall Risk Assessments, Mini-Mental Status Examinations, and Depression Screenings, and incorporate findings into the care plan.
• Use nursing judgment to identify safety issues, changes in condition, and gaps in care; proactively intervene and escalate when appropriate.
• Develop individualized plans of care in collaboration with clients and families, focusing on safety, chronic disease management, medication oversight, independence, and quality of life.
• Recommend and coordinate services such as home health, therapy, PCP and specialist follow-up, durable medical equipment, in-home support, and community resources.
• Collaborate with hospitals, nursing homes, assisted living and memory care staff, physicians, and other medical providers to ensure smooth transitions of care (admission, discharge, post-hospital follow-up).
• Communicate with attorneys, financial planners, Meals on Wheels, and other community partners involved in each client's broader support system.
• Perform regular home or facility visits to monitor clinical status, environment, adherence to recommendations, and overall well-being; update care plans as needs change.
• Provide ongoing emotional support, education, and counseling to clients and families regarding diagnosis, prognosis, care options, and advance planning.
• Offer crisis intervention and use strong critical thinking to manage urgent situations (falls, hospitalizations, sudden decline, caregiver burnout), coordinating with providers and family as needed.
• Partner with the business development team to meet with prospective clients, families, and referral sources to explain RN-led care management services and benefits.
• Provide back-up support to fellow Care Managers as needed.
• Thoroughly document assessments, care plans, communications, and interventions; carefully track and record time spent on each client to support accurate billing and clear communication.
• Participate in ongoing nursing and care management education, CE opportunities, and networking events to stay current on best practices in senior care and care coordination.