Case Manager

Job Description

Job Description

Role Summary

The Case Manager is a vital member of the Interdisciplinary Care Team, working collaboratively to deliver and manage all aspects of participant care. This role involves conducting assessments, developing care plans, addressing patient needs, and advocating for participants. The Case Manager delivers care in various settings, including the center, participants' homes, and skilled nursing facilities.

• Take ownership of outcomes and quality of care for assigned participants, working closely with the Primary Care Provider (PCP).
• Conduct required assessments in various settings and educate participants and their support networks on medical conditions.
• Develop and implement a discipline-specific plan of care in collaboration with the Interdisciplinary Team (IDT) and participants.
• Identify participant needs, prioritize effectively, and collaborate with the PCP and IDT members.
• Coordinate care for participants with complex needs, ensuring seamless transitions and preventing unnecessary hospitalizations.
• Manage clinical tasks such as reviewing test results, documenting procedures, and following up on participant changes.
• Coordinate participant discharges and transitions of care, including medication needs and hospice transitions.
• Support clinic operations in the absence of supervisory roles, as needed.
• Act as a coordinator of care, evaluating and following up on patient care measures.

• Minimum of two years of nursing experience in a clinical setting with a frail or elderly population.
• Strong nursing knowledge and skills for managing complex clinical situations.
• Highly motivated and self-directed, capable of making sound decisions in emergency situations.
• Excellent clinical, organizational, and communication skills, especially in settings with seniors and interdisciplinary team members.
• Ability to multitask and contribute to projects, timelines, and process improvement initiatives.
• Experience working with people from diverse backgrounds and cultures.
• Commitment to unlocking the full potential of vulnerable seniors.

• Bilingual English/Spanish preferred.

Monday to Friday, 8:00 AM to 4:30 PM. Candidates must have reliable transportation.