Registered Nurse - Case Manager

About This Role

As an RN, Case Manager, you will partner with primary care providers to lead care management and coordination activities for complex patients within a value-based care environment. This role focuses on preventing avoidable admissions, optimizing resource utilization, and ensuring effective team-based care for improved patient outcomes.

Responsibilities

• Manage an assigned caseload of complex patients to reduce admissions, readmissions, and medical utilization
• Accountable for panel metric performance in admission prevention, readmission prevention, and transitions of care
• Own overall care coordination for assigned patients, acting as the primary point of contact and ensuring team alignment
• Manage transitions of care episodes, including clinical assessments, medication reconciliation, and addressing needs
• Collaborate with PCPs, families, Social Workers, Behavioral Health Specialists, and care team members to evaluate needs and plan of action
• Ensure timely documentation of key clinical assessments after admissions and balance in-center care team planning meetings
• Lead in-person interdisciplinary care planning meetings for effective care coordination
• Perform timely nursing assessments and provide patient education for chronic condition management and transitions of care
• Educate patients and families, empowering them in their care, and advocating for their needs
• Document visits in electronic health record according to internal standards

Requirements

• Current RN license in assigned state
• Minimum of 6-8 years nursing experience
• Certified Case Manager (CCM) required, or willingness to obtain within 12 months of hire
• US work authorization
• Access to reliable transportation and ability to travel throughout communities

Qualifications

• Bachelor degree in nursing preferred
• Minimum of 6-8 years nursing experience

Nice to Have

• Bachelor degree in nursing
• 2+ years experience in transitional nursing, emergency room nursing, care coordination, discharge planning, or home health
• Demonstrated skill in motivational interviewing, patient activation, time management, and navigating community and social resources
• A flexible and positive attitude
• Comfort with ambiguity and change
• High emotional intelligence

Benefits

Certifications