Nurse Case Manager

AccordCare; Carle Place (NY); On-site; USD 60,000 - 85,000; Full time

Job summary

AccordCare is seeking a Clinical Position in Carle Place, NY, focused on completing assessments and developing individualized care plans. The role includes providing field clinical oversight, monitoring outcomes, and ensuring compliance with regulations.

Candidates should have strong clinical knowledge and communication skills. A commitment to quality improvement in care delivery is essential, and participation in an on-call rotation will be required. Join AccordCare to make a difference in client lives.

Qualifications

• Strong understanding of clinical assessments and care planning.
• Ability to monitor outcomes and implement quality improvement strategies.
• Effective communication skills with clients, families, and stakeholders.

Responsibilities

• Complete and document assessments and care plans as per standards.
• Provide field-based clinical oversight to ensure care delivery.
• Communicate clinically relevant changes to all stakeholders.
• Maintain accurate documentation in compliance with regulations.
• Participate in on-call rotation for urgent client issues.

Job description

Description

• Completes and documents initial assessments, reassessments, and significant change in condition assessments for new starts, restarts, and ongoing cases in the EMR per company standards and applicable state requirements.
• Develops, implements, and updates individualized plans of care based on assessed needs, client/family goals, and provider direction.
• Identifies clinical risks and changing conditions; initiates timely interventions and escalations to the appropriate provider, family, internal leadership, or emergency services when indicated.
• Collaborates with clients/families to set realistic goals and ensure day-to-day care supports those goals.
• Monitors clinical outcomes and identifies opportunities for quality improvement and enhanced care delivery.

Clinical Assessment & Care Planning

• Completes and documents initial assessments, reassessments, and significant change in condition assessments for new starts, restarts, and ongoing cases in the EMR per company standards and applicable state requirements.
• Develops, implements, and updates individualized plans of care based on assessed needs, client/family goals, and provider direction.
• Identifies clinical risks and changing conditions; initiates timely interventions and escalations to the appropriate provider, family, internal leadership, or emergency services when indicated.
• Collaborates with clients/families to set realistic goals and ensure day-to-day care supports those goals.
• Monitors clinical outcomes and identifies opportunities for quality improvement and enhanced care delivery.

Field Clinical Oversight & Care Professional Support

• Provides field-based clinical oversight to ensure care is delivered safely and consistent with the plan of care and scope of practice.
• Educates and coaches Care Professionals on client-specific care needs, safety, infection prevention, documentation expectations, and red flags for escalation.
• Communicates care plan updates and client status changes to Care Coordinators and assigned care professionals to support safe staffing and continuity of care.
• Identifies caregiver training needs and collaborates with internal leadership to coordinate competency development and education.

Provides clinical feedback regarding Care Professional performance, including adherence to care plans, documentation accuracy, and clinical skills. Escalates concerns through appropriate internal channels.

Coordination, Orders, and Stakeholder Communication

• Communicates clinically relevant changes to practitioners and other stakeholders; requests/obtains practitioner orders as applicable to the service model and state requirements.
• Prepares accurate reports/updates for external stakeholders (e.g., care managers, payers, facilities, referral sources) as required for the case.
• Serves as a clinical liaison to strengthen relationships with clients, families, referral partners, and community providers.

Documentation & Compliance

• Maintains timely and accurate documentation in the EMR according to company policy, payer expectations (when applicable), and state/federal regulatory requirements.
• Documents field visits, assessments, care plan updates, caregiver instructions, and follow-up actions.
• Ensures required client documentation is available and maintained in both electronic and in-home formats when applicable.
• Protects confidentiality and complies with HIPAA and company privacy/security standards.

On-Call / Coverage (As Assigned)

• Participates in an on-call rotation as assigned, responding to clinical questions, urgent client issues, and changes in condition consistent with the 24/7 nature of home care.
• Maintains expected service and documentation standards during on-call coverage.

Other Duties

• Performs other related duties as assigned, consistent with licensure, competency, and business needs.