Nurse Case Manager

Overview Position Type Full Time Job Shift Day Education Level 2 Year Degree Travel Percentage Up to 50% Category Health Care ## Description The Nurse Case Manager is a Licensed Practical Nurse (LPN) or Registered Nurse (RN) who provides direct clinical care, care coordination, and case management for approximately 15-20 individuals with medical fragility, Intellectual and Developmental Disabilities (IDD), and Mental Health (MH) diagnoses living in Pennsylvania group homes regulated under 6400 standards. The role combines hands-on nursing care with case management to ensure services are timely, person-centered, cost-effective, and aligned with individual needs. Responsibilities include clinical care such as obtaining weights and blood pressure, wound assessment, and catheter care; coordinating appointments and services; managing medication and equipment needs; supporting care transitions; and training direct support professionals (DSPs) to recognize emergencies and provide daily care that promotes positive health outcomes. DUTIES AND RESPONSIBILITIES: 1. Perform clinical tasks including, but not limited to, wound care, feeding pump support, fall-risk assessment, lung and abdominal exams, post-ER and post-hospitalization assessments, and troubleshooting catheters, feeding pumps, and adaptive durable medical equipment. 2. Conduct comprehensive nursing assessments to identify medical, functional, behavioral, psychosocial, and support needs, along with related risks and barriers. 3. Develop, implement, and update individualized care plans and nursing recommendations based on physician orders, assessments, individual goals, and changing needs. 4. Train and coach staff on personal care, repositioning, vital signs, emergency recognition, and response to urgent medical situations, including 911 emergencies. 5. Coordinate care with contracted nurses, physicians, specialists, therapists, hospital staff, and community providers to ensure continuity of care. 6. Monitor health status and treatment response, follow up on recommendations, and adjust care coordination priorities to support safe transitions and positive outcomes. 7. Obtain needed education and train staff on the proper use of prescribed adaptive equipment, nutrition plans, and required meal textures. 8. Serve as the primary contact for physicians and specialists by preparing appointment paperwork and supplying relevant test results, referrals, authorizations, and treatment information. 9. Maintain accurate, timely, and confidential documentation in the electronic health record, including medical history, case notes, assessments, appointments, and care coordination activity. 10. Order new medications and refills through the pharmacy system, communicate medication changes, and confirm medications are received by the homes. 11. Support and review medication administration record (MAR) documentation, observe medication administration, and provide feedback to ensure compliance and accuracy. 12. Audit medications to ensure correct texture, preparation, and administration method. 13. Educate individuals, families, medical decision makers, next of kin, and staff on diagnoses, treatment plans, medications, equipment, and available resources. 14. Coordinate care during ER visits, hospitalizations, and discharges, communicate with hospital staff, update records with new orders, and ensure follow-up recommendations are implemented. 15. Advocate for access to healthcare services, benefits, equipment, and community-based supports. 16. Participate in team meetings, case conferences, quality improvement activities, and medical appointments as required. 17. Keep electronic and paper charts current to support staff access to accurate information and promote health and safety. 18. Completes HRST Clinical Reviews of those in their caseload and communicates changes to the team. 19. Participate n rotating on-call duties as assigned. 20. Perform other duties as assigned. ## Qualifications Education/Experience/Skills Requirements 1. Active Pennsylvania licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN). 2. Experience in Community Living Arrangements, care coordination, and case management. 3. Three (3) years of experience supporting individuals with multiple disabilities, including knowledge of safety and communication needs for individuals with physical disabilities. 4. Strong clinical judgment and the ability to solve problems and make decisions independently. 5. Experience with feeding tubes, colostomies, tracheotomies, catheter care, and wound care strongly preferred. 6. Knowledge of healthcare regulations, payer requirements, community resources, and documentation standards relevant to the role. 7. Ability to manage multiple priorities in a fast-paced environment with strong attention to detail, organization, and time management. 8. Ability to work effectively on an interdisciplinary team and communicate clearly in writing and verbally. 9. Ability to anticipate changes, identify issues, and take appropriate action. 10. Intermediate proficiency in Microsoft Word, Excel, Outlook, SharePoint, and PowerPoint. 11. Experience using electronic management systems and electronic health records. 12. Ability to perform CPR, First Aid, and crisis intervention using agency-trained protocols. 13. Ability to attend off-site meetings as needed. 14. Ability to work nights and weekends as needed.