RN Case Manager

RN Case Manager

We are seeking a compassionate, clinically skilled, and highly motivated Registered Nurse (RN) Case Manager to join a collaborative healthcare team dedicated to providing comprehensive, patient-centered care to older adults!

This is an excellent opportunity for an experienced RN who enjoys building meaningful relationships with patients, coordinating complex care needs, and making a positive impact on the health and well-being of seniors.

As an RN Case Manager, you will work closely with Primary Care Providers (PCPs) and a multidisciplinary care team to coordinate and manage all aspects of patient care. You will conduct comprehensive clinical assessments, develop individualized care plans, provide patient education, manage complex clinical needs, and ensure continuity of care across healthcare settings.

This is a hands-on clinical case management position, combining direct patient care, comprehensive assessments, care coordination, clinical decision-making, and patient advocacy.

You will provide care in the clinic, patients' homes, skilled nursing facilities, and other short-term or long-term care settings as needed.

The position includes three on-site days and two mobile days per week, allowing you to provide both clinic-based care and direct support to patients in their homes.

The ideal candidate has recent nursing experience involving ongoing comprehensive assessments, care coordination, and complex clinical decision-making across a diverse patient population.

If you are passionate about supporting older adults, strengthening patient outcomes, and providing compassionate, coordinated healthcare, this could be an excellent opportunity!

Duties & Responsibilities

Clinical Case Management & Patient Care

• Take ownership of the outcomes and quality of care for an assigned panel of patients, working directly with the Primary Care Provider and utilizing clinic resources to practice at the top of the RN license.
• Conduct required comprehensive patient assessments in the clinic, patients' homes, and virtually, at least every six months.
• Perform urgent and routine virtual or in-person follow-up visits based on patient risk stratification, clinical needs, and direction from the Primary Care Provider.
• Assess patient needs, identify clinical concerns, determine priorities, and escalate issues appropriately to the Primary Care Provider.
• Apply clinical judgment and nursing knowledge to manage complex patient conditions and implement appropriate nursing measures.
• Perform and document ordered nursing procedures and care in the clinic or patient's home when required or deemed necessary, within the RN scope of practice and as directed by the Primary Care Provider.
• Monitor patient conditions, recognize changes, and implement nursing measures related to potential or developing clinical problems.

Individualized Care Planning & Patient Education

• Develop and implement discipline-specific plans of care in collaboration with the care team, patients, families, and authorized representatives or Powers of Attorney (POAs).
• Ensure care plans support high-quality, value-based, holistic, compassionate, and patient-centered care.
• Educate patients and their support networks regarding acute, chronic, and end-stage medical conditions.
• Document assessments, clinical findings, relevant patient information, care plans, and actions accurately and promptly in the Electronic Health Record (EHR).
• Advocate for patient needs and coordinate appropriate follow-up care.

Complex Care Coordination & Transitions of Care

• Coordinate care for patients with the highest levels of clinical complexity, including individuals receiving treatment in hospitals, emergency departments, and skilled nursing facilities.
• Collaborate with the Complex Care Team to support seamless transitions of care, improve patient satisfaction, prevent unfavorable outcomes, reduce inappropriate resource utilization, and avoid unnecessary hospitalizations.
• Coordinate patient discharges and transitions of care, including post-discharge medication needs.
• Facilitate transitions into and out of hospice services and monitor monthly hospice census information with the hospice agency.
• Communicate patient changes to the care team, including post-procedure or post-discharge needs and changes in level of care, medical condition, or functional status.

Clinical Follow-Up & Provider Collaboration

• Collaborate with the Primary Care Provider to manage the Clinical Inbox, ensuring orders are completed promptly.
• Review test results, medical evaluations, and clinical documentation with the provider.
• Ensure appropriate follow-up actions are completed, documented, and communicated to patients.
• Coordinate and support patient communication, clinical triage, and ongoing patient care needs.
• Participate in multidisciplinary team meetings for the assigned patient group.
• Support population management and ongoing patient management for the assigned group of patients.

Patient Advocacy & Healthcare Coordination

• Coordinate care on behalf of patients with healthcare personnel and other members of the care team.
• Evaluate and follow up on patient care needs, including:
• Dentures and glasses
• Personal care services
• Medical procedures
• Laboratory testing
• Referrals
• Transportation
• Communicate with patients and families regarding care needs, clinical concerns, and follow-up plans.
• Help ensure patients receive appropriate services and coordinated support across care settings.

Clinic Support & Team Collaboration

• Collaborate with the Primary Care Provider and care team to support the delivery and coordination of patient care.
• In the absence of the Clinic Supervisor, Clinic Nurse, or Clinical Coordinator, provide support for specific relevant tasks associated with those roles as needed.
• Participate in team activities, assigned projects, timelines, and process improvement initiatives.
• Maintain effective communication with patients, families, clinical providers, and team members.

Required Qualifications

Education

• Graduate of an accredited School of Nursing.

Licensure & Certifications

• Current, unencumbered Registered Nurse (RN) license.
• Current Basic Life Support (BLS) certification.

Clinical Experience

• Minimum of 2 years of nursing experience in a clinical setting working with a frail or elderly population.
• Nursing knowledge and clinical skills necessary to treat frail, elderly patients and manage complex clinical situations.
• Ability to perform comprehensive clinical assessments, develop individualized plans of care, and coordinate patient needs.
• Ability to apply sound clinical judgment and make appropriate decisions in emergency situations.
• Ability to work effectively with patients requiring ongoing clinical assessment, care coordination, and complex care management.

Professional Skills & Competencies

• Excellent clinical, organizational, interpersonal, and communication skills.
• Ability to communicate effectively with seniors, their families, and multidisciplinary healthcare team members.
• Highly motivated, self-directed, and able to execute tasks in a rapidly changing environment.
• Ability to work independently with minimal supervision.
• Demonstrated ability to prioritize responsibilities in a fast-paced clinical environment.
• Strong multitasking skills and ability to contribute to projects, activities, timelines, and process improvement initiatives.
• Experience and competency working with individuals from diverse backgrounds and cultures.
• Ability to document patient assessments, care plans, and clinical information in an Electronic Health Record (EHR).
• Commitment to supporting the health, independence, and well-being of vulnerable seniors.

Transportation & Schedule Requirements

• Reliable transportation required for clinic-facing responsibilities and patient home visits.
• Ability to work Monday through Friday, 8:00 AM-4:30 PM.
• Availability for three on-site days and two mobile days per week to conduct patient home visits.

Desired Qualifications

• Bilingual English/Spanish preferred , with the ability to speak, read, and write in Spanish.

Why Consider This Opportunity?

• Meaningful Patient Relationships: Provide ongoing care and advocacy for older adults with diverse healthcare needs.
• Hands-On