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 Requirements 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. Highest-signal resume keywords Registered Nurse (RN) License Clinical Work Experience Community Case Management Experience Certified Case Manager (CCM) Basic Life Support (BLS) Certification ATS Optimization Keywords Hard Skills 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 Soft Skills Interpersonal Skills Communication Skills Critical Thinking Organizing Skills Autonomous Work Ability Certifications & Qualifications Registered Nurse (RN) License Certified Case Manager (CCM) Basic Life Support (BLS) Certification Industry Keywords Case Management Patient Care Healthcare Systems Community Resources Multidisciplinary Team Coordination Tools & Technologies Microsoft Office Suite Excel Word PowerPoint Outlook #J-18808-Ljbffr