RN Case Manager - Home Health | Admissions & Care Coordination

Join a Mission-Driven Team Making a Meaningful Difference Every Day

At Agape’s Way Healthcare Services, we provide specialized home health services to individuals with complex healthcare needs. Our team is committed to delivering safe, compassionate, coordinated care while ensuring every patient receives services that align with their individualized plan of care.

We are seeking an experienced and highly organized Registered Nurse (RN) Case Manager to serve as a key clinical resource throughout the patient journey—from referral and pre-admission assessment through ongoing case management, care transitions, and discharge.

This is an excellent opportunity for an RN who enjoys combining clinical judgment, care coordination, documentation, and interdisciplinary collaboration . If you are the type of nurse who notices what is missing, follows details through to completion, and understands how strong clinical coordination improves both patient care and operational outcomes, we want to hear from you.

Why Join Agape’s Way?

• Mission-driven organization focused on compassionate, patient-centered care
• Opportunity to use your RN expertise beyond traditional bedside nursing
• Meaningful involvement throughout the full patient episode of care
• Combination of field-based clinical assessment and clinical record coordination
• Collaborative environment working with nursing, physicians, referral partners, intake, authorization, scheduling, and billing
• Opportunity to support medically complex patients in community-based settings
• Professional growth and clinical leadership opportunities
• Competitive compensation and benefits package

Position Overview

The RN Case Manager provides clinical support for assigned patients receiving Agape’s Way Home Health Services.

This position conducts in-person pre-admission bedside assessments and coordinates the clinical documentation and follow-through required for admissions, ongoing patient records, physician and allowed-practitioner appointments and orders, referrals, authorizations, transfers, discharges, and billing-denial support.

The RN Case Manager maintains oversight of the assigned clinical record, identifies missing or inconsistent documentation, monitors time-sensitive requirements, and collaborates across departments to help ensure services remain aligned with the patient’s individualized plan of care.

The position exercises Registered Nurse judgment within Florida law, Agape’s Way policies, applicable payer requirements, and the authority of the Director of Nursing.

Reports to: Director of Nursing (DON)

Work Setting: Field / Group Home Settings

Schedule: Monday - Friday - 8:00 AM - 5:00 PM

What You’ll Do

Admissions & Pre-Admission Assessments

• Review assigned referrals for clinical completeness, ordered services, patient needs, safety considerations, and appropriateness for Agape’s services
• Travel to hospitals, private homes, group homes, skilled nursing/rehabilitation facilities, and other authorized referral locations to conduct in-person bedside assessments
• Assess prospective patients’ clinical condition, functional and cognitive status, medications, treatments, equipment needs, risks, support systems, and anticipated home health needs
• Apply established admission criteria and provide a documented clinical recommendation regarding patient fit and safety
• Complete or coordinate required initial and comprehensive nursing assessments
• Verify required orders, consents, authorizations, medication information, and supporting clinical records for start of care
• Establish admission documentation in the approved electronic medical record and communicate relevant risks, schedules, and follow-up needs to the care team

Clinical Case Management & Record Coordination

• Maintain clinical oversight of an assigned caseload throughout the episode of care
• Review plans of care, assessments, medication profiles, practitioner orders, visit notes, authorizations, hospital records, and other clinical documentation
• Identify missing, incomplete, inconsistent, or time-sensitive documentation
• Track outstanding signatures, orders, authorizations, reassessments, recertifications, addenda, and other clinical requirements through completion
• Compare delivered services with the current plan of care and authorized schedule
• Escalate missed visits, service gaps, changes in condition, safety concerns, and unresolved clinical barriers appropriately
• Maintain patient confidentiality and ensure protected health information is handled through authorized systems and communication channels

Physician Appointments & Clinical Orders

• Coordinate clinical preparation and follow-through for physician and allowed-practitioner appointments
• Prepare or obtain relevant clinical summaries, medication information, observations, questions, and required documentation
• Obtain and process visit notes, test results, referrals, new or changed orders, and follow-up instructions
• Reconcile new clinical information with existing plans of care and medication profiles
• Identify discrepancies and coordinate clarification with authorized practitioners
• Communicate significant changes in condition or failure to meet expected outcomes promptly through the appropriate clinical chain

Transfers, Discharges & Care Transitions

• Coordinate clinical requirements related to hospitalizations, resumptions of care, transfers, and discharges
• Ensure required assessments, summaries, notifications, orders, and patient instructions are completed
• Collaborate with patients, representatives, practitioners, Agape clinicians, referral partners, and other authorized participants to support continuity of care
• Ensure discharge and transfer records accurately reflect patient status, unresolved needs, follow-up arrangements, and the reason for transition
• Coordinate authorized transmission of clinical records when appropriate

Authorizations, Denials & Clinical Revenue Support

• Partner with Intake, Authorization, Scheduling, and Billing to ensure clinical documentation supports ordered and delivered services
• Review the clinical components of payer denials, documentation requests, audits, and appeals
• Identify missing evidence, response requirements, deadlines, and appropriate owners
• Compile supporting clinical records and prepare factual clinical chronologies or draft appeal narratives for authorized review
• Track authorization and denial-related follow-up through resolution
• Identify recurring documentation, ordering, scheduling, or communication issues that may contribute to preventable denials
• Maintain clinical accuracy and integrity throughout the revenue-support process

Interdisciplinary Coordination & Quality

• Participate in case conferences and communicate current patient goals, risks, barriers, changes, and follow-up responsibilities
• Collaborate with nursing, physicians, practitioners, referral sources, billing, authorization, scheduling, and other authorized care partners
• Support incident, complaint, hospitalization, change-of-condition, and survey follow-up
• Provide record-based coaching to clinicians regarding documentation expectations
• Escalate repeated or serious documentation deficiencies to appropriate leadership
• Participate in quality assurance and performance improvement initiatives
• Participate in clinical on-call or urgent case/record follow-up when scheduled

What Success Looks Like

A successful RN Case Manager will consistently demonstrate:

• Timely and thorough pre-admission bedside assessments
• Strong clinical judgment and appropriate escalation
• Organized, complete, and audit-ready clinical records
• Effective management of competing deadlines and caseload priorities
• Timely follow-through on missing orders, signatures, authorizations, and documentation
• Strong coordination of admissions, appointments, transfers, and discharges
• Accurate clinical support for authorization and denial-related needs
• Clear and professional interdisciplinary communication
• Consistent follow-through from identification of an issue through resolution
• Commitment to documentation integrity, patient safety, and regulatory compliance

These performance expectations are specifically emphasized in the JD, including evaluating performance based on timeliness, completeness, accuracy, communication, follow-through, and corrective-action effectiveness rather than simply focusing on incident or denial counts.

Qualifications

• Current, active, and unrestricted Registered Nurse (RN) license in the State of Florida
• Graduate of an approved nursing education program
• Bachelor of Science in Nursing (BSN) preferred
• Minimum of two (2) years of professional nursing experience
• Home health, case management, pre-admission/bedside assessment, utilization review, clinical documentation, or medically complex community-care experience strongly preferred
• Current Basic Life Support (BLS) certification from an approved provider
• Strong knowledge of nursing assessment, plans of care, practitioner orders, medication reconciliation, care transitions, and clinical documentation
• Familiarity with payer authorization and healthcare documentation requirements
• Experience with electronic medical records and clinical document tracking
• Strong written clinical communication and documentation skills
• Ability to manage a high-volume caseload and multiple competing deadlines
• Excellent organizational, critical-thinking, and problem-solving skills
• Ability to identify unresolved issues and follow them through completion or appropriate escalation
• Strong professional communication skills when working with patients, representatives, practitioners, referral partners, clinicians, and administrative teams
• Valid driver’s license and reliable transportation
• Ability and willingness to travel between hospitals, private homes, group homes, skilled nursing/rehabilitation facilities, practitioner offices, and other assigned locations
• Ability to successfully complete required background screening, health, and competency requirements

The RN Behind the Continuity of Care

Great case management is about more than maintaining a chart.

It is recognizing what a patient needs, ensuring the right information reaches the right people, identifying gaps before they affect care, and following every important detail through to completion.

If you are an experienced Florida RN who combines clinical judgment with exceptional organization, communication, and follow-through , we encourage you to join Agape’s Way Healthcare Services.

Coordinate the care. Connect the details. Protect the patient journey.