Geriatric RN Case Manager — Hybrid Clinic & Home Visits

TEEMA; Carson (CA); Hybrid; USD 69,000 - 74,000; Full time

Job summary

TEEMA is seeking an experienced Registered Nurse Case Manager to coordinate care for frail and elderly patients in a hybrid clinic and field-based setting in Carson, CA. You will manage an assigned patient panel, perform comprehensive assessments, and develop Plans of Care across clinic, home, and virtual environments.

The role emphasizes case management, clinical assessment, and collaboration with PCPs and the care team to prevent hospitalizations and optimize outcomes.

Qualifications

• Graduate of an accredited School of Nursing.
• Active BLS certification.
• Minimum 2 years of nursing experience caring for frail or elderly patients in a clinical setting.
• Strong clinical assessment and critical-thinking skills.
• Excellent communication, organization, and care coordination abilities.
• Ability to work independently and manage multiple priorities.
• Comfortable conducting local home visits approximately 2–5 times per week.
• Experience working with patients from diverse backgrounds.

Responsibilities

• Manage care and clinical outcomes for an assigned panel of patients.
• Complete comprehensive nursing assessments in the clinic, virtually, and during home visits.
• Develop and update individualized Plans of Care (POC).
• Educate patients and families regarding acute, chronic, and end-stage conditions.
• Identify changes in patient condition and escalate as needed.
• Coordinate complex care and transitions between hospitals, ERs, SNFs, Hospice, and home settings.
• Help prevent avoidable hospitalizations through proactive care coordination and follow-up.
• Coordinate services including specialists, labs, procedures, personal care, dental, vision, and transportation.
• Partner with PCPs to process medical orders, review results, and coordinate follow-up care.
• Perform nursing procedures and direct clinical care as ordered.
• Maintain accurate and timely documentation within the Electronic Health Record (EHR).
• Collaborate closely with patients, families, physicians, and the interdisciplinary care team.

Skills

Active BLS certification

2+ years nursing experience

Strong clinical assessment

Excellent communication

Care coordination

Independent work

Education

Graduate of an accredited School of Nursing

Job description

TEEMA is seeking an experienced Registered Nurse Case Manager to coordinate care for frail and elderly patients in a hybrid clinic and field-based setting in Carson, CA. You will manage an assigned patient panel, perform comprehensive assessments, and develop Plans of Care across clinic, home, and virtual environments.

The role emphasizes case management, clinical assessment, and collaboration with PCPs and the care team to prevent hospitalizations and optimize outcomes.