RN Case Manager

Job Description

Job Description

Role Summary

Are you a dedicated Registered Nurse who is passionate about delivering holistic, high-quality care to older adults? We are seeking an energetic and collaborative Case Manager to join our dynamic care team!

In this empowering clinical role, you will take ownership of care outcomes for an assigned panel of patients, working in close partnership with Primary Care Providers (PCPs) and an interdisciplinary team to deliver compassionate, value-based care. You will conduct comprehensive clinical assessments, design individualized plans of care, manage transitions across health settings, and provide direct nursing interventions in clinic, virtual, and home settings. If you thrive in a fast-paced environment and want to make a meaningful, lasting impact in senior care, this opportunity offers a rewarding path to utilize your full nursing license!

Duties & ResponsibilitiesPatient Advocacy & Care Planning

• Take complete ownership of quality care and clinical outcomes for an assigned patient panel, practicing at the top of your nursing license in partnership with the PCP.

• Conduct required clinical assessments (at least every six months) in the clinic, virtually, or during home visits to evaluate patient health status and risk levels.

• Develop, implement, and update discipline-specific Plans of Care (POC) in collaboration with the team, patients, families, and power of attorney (POA) representatives.

• Educate patients and their support networks on managing acute, chronic, and end-stage conditions.

• Identify overt patient needs, establish care priorities, perform routine or urgent follow-up visits, and appropriately escalate concerns to the PCP.

• Coordinate care for complex patients across hospitals, emergency rooms, skilled nursing facilities, and home environments alongside the Complex Care Team to ensure smooth care transitions and prevent avoidable hospitalizations.

• Facilitate transitions in and out of hospice care and monitor monthly census records with hospice agencies.

• Act as a primary care coordinator on behalf of patients regarding essential health services, including personal care, lab orders, procedures, specialists, dental, vision, and transportation needs.

• Partner with the PCP to manage the clinical inbox—ensuring medical orders are processed promptly, test results are reviewed, and required follow-up actions are taken and communicated.

• Perform ordered nursing procedures and direct clinical care in the clinic or during home visits as required.

• Communicate changes in level of care, condition, functional status, or post-procedure needs promptly to the broader team.

• Support clinic operations by assisting with relevant supervisory or coordination tasks as needed to maintain smooth care delivery.

• Accurately capture all assessments, findings, and care actions with timely, compliant Electronic Health Record (EHR) documentation.

• Other duties as assigned.

Required QualificationsEducation, Licensure & Credentials

• Education: Graduate of an accredited School of Nursing.

• Licensure: Active, unencumbered Registered Nurse (RN) License.

• Certification: Active Basic Life Support (BLS) certification.

Experience & Core Competencies

• Eldercare Focus: Minimum of two (2) years of nursing experience in a clinical setting caring for a frail or elderly population.

• Clinical Knowledge: Strong clinical assessment and decision-making skills required to manage complex situations with seniors.

• Communication & Organization: Excellent clinical, organizational, and multi-tasking skills, with the ability to prioritize tasks in a fast-paced environment.

• Self-Direction: Highly motivated and capable of working independently with minimal supervision while making sound decisions in emergency situations.

• Cultural Competency: Experience and competency in working effectively with individuals from diverse backgrounds and cultures.

Desired Qualifications

• Language Abilities: Bilingual fluency in English and Spanish (verbal and written) is preferred.

Location and Work Type

• Work Type: Full-Time Contract Position (40 hours per week; 13-week assignment).

• Work Setting: Hybrid Clinic & Field-Based Setting located in Carson, CA . Requires potential local travel 2–5 times per week to perform home visits in the immediate surrounding area.

• Schedule: Monday through Friday, 8:00 AM – 4:30 PM .

If you're interested, please reply to this advertisement or directly email your resume to me at View email address on us.fitly.work or by calling/texting View phone number on us.fitly.work.
I strive to reply within 48 hours. Looking forward to connecting with you soon. Thank you!