Case Manager

RN Case Manager

Job Location: San Jose, CA Job Duration: 13 weeks with Possibility of Extension Shift: M–F, 8:00 AM–4:30 PM| 40 Hour a week Pay Rate: $60/hour on W2

Job Description: The RN Case Manager is a member of the Interdisciplinary Care Team (ICT) responsible for coordinating and managing comprehensive care for frail and elderly participants. The Case Manager conducts required PACE assessments, develops individualized care plans, provides nursing care across clinic, home, and post-acute settings, and collaborates with the Primary Care Provider (PCP), participants, families, and interdisciplinary team members. The role focuses on delivering participant-centered care, coordinating transitions, addressing complex clinical needs, and promoting quality outcomes.

Job Responsibilities:

• Conduct required PACE assessments in the clinic, participants' homes, and virtually, at least every 6 months.
• Assess participant needs, identify clinical concerns, prioritize care needs, and escalate issues appropriately to the Primary Care Provider.
• Develop and implement individualized, discipline-specific plans of care in collaboration with the ICT, participants, families, or POAs.
• Provide routine and urgent in-person or virtual follow-up based on participant risk stratification and clinical needs.
• Perform and document ordered nursing procedures and care in the clinic or participant's home in accordance with scope of practice and PCP direction.
• Coordinate care for complex participants receiving hospital, emergency room, skilled nursing facility, or other levels of care.
• Collaborate with the Complex Care Team to support seamless transitions of care, including hospital and facility discharges.
• Review medical test results, evaluations, orders, and clinical documents; coordinate timely follow-up and communicate appropriate information to participants.
• Monitor and communicate changes in participant condition, functional status, level of care, post-procedure needs, and post-discharge requirements to the interdisciplinary team.
• Coordinate medication needs and transitions in and out of hospice, including monitoring the monthly hospice census.
• Educate participants and their support networks regarding acute, chronic, and end-stage conditions and ongoing care needs.
• Coordinate participant services and resources, including referrals, laboratory services, procedures, transportation, personal care, dentures, and glasses.
• Document assessments, findings, care plans, interventions, and follow-up actions accurately and timely in the EHR.
• Provide clinic and care coordination support as needed in the absence of the Clinic Supervisor, Clinic Nurse, or Clinical Coordinator.

Required Qualifications:

• Graduate of an Accredited School of Nursing.
• Unencumbered RN License.
• BLS certification.
• Minimum 2 years of nursing experience in a clinical setting with a frail or elderly population.
• Strong nursing knowledge and clinical skills necessary to care for frail, elderly participants and manage complex clinical situations.
• Experience working effectively with people from diverse backgrounds and cultures.
• Reliable transportation required for clinic-facing clinical work.

Preferred Experience:

• Bilingual English/Spanish preferred.