Registered Nurse (R.N.) Geriatric Case Manager - Home Care (Full-Time, Days)

Rochester Regional Health; United States; On-site; USD 76,000 - 101,000; Full time

Job summary

Rochester Regional Health Home Care is seeking a Geriatric Case Manager to deliver comprehensive nursing care under the GSV program. The RN will conduct pre-surgical assessments, identify post-discharge needs, and develop, implement, and evaluate an appropriate Plan of Care with patients and families.

The role coordinates interdisciplinary services, supervises care delivery, and ensures patient-centered outcomes while supporting program growth and quality improvement in a home-based setting.

Qualifications

• Associates Degree in Nursing required.
• Minimum 2 years nursing experience in home care or geriatric case management.
• Registered Nurse license in New York State.
• Valid NYS Driver’s License.
• Master’s in Nursing: Healthcare Leadership or Geriatric NP preferred.

Responsibilities

• Conducts Comprehensive Assessments of older adults’ physical, emotional, cognitive, and social needs, including pre-surgical in-home evaluations and post-discharge follow-up, with a focus on identifying and addressing Social Determinants of Health.
• Develops and Implements Interdisciplinary Care Plans in collaboration with patients, caregivers, and healthcare teams to support recovery and independence in the least restrictive setting.
• Coordinates and Monitors Care by navigating health systems, ensuring timely services, tracking patient progress, and adjusting care plans as needed to meet individual goals.
• Responds to Health Crises and Advocates for Patients, addressing emergencies like hospitalizations and ensuring high-quality, patient-centered care aligned with individual preferences.
• Provides Leadership and Quality Oversight, including supervising care teams, mentoring new staff, documenting thoroughly, participating in quality improvement, and supporting program growth.

Skills

Nursing

Education

Associates Degree in Nursing

Job description

Job Title: Geriatric Case Manager

Department: Homecare | Location: Rochester Regional Health Home Care - Monroe Avenue | Schedule: Monday - Friday, 8:30am to 4:30pm

Rochester Regional Health Home Care is the only home care provider in the region to earn a CMS 5-Star Quality of Patient Care rating, placing its CHHA among the top 3.5% of agencies nationwide. In addition, CHHA was recognized by U.S. News & World Report as a “High Performing Home Care Agency,” further highlighting its commitment to exceptional patient care and clinical excellence.

SUMMARY

The role is responsible for the delivery of comprehensive nursing care to a set of assigned patients thru the RRH Geriatric Service Verification program. This involves the pre-surgical assessment of eligible patients in the GSV program. The RN will work with the patient, family, Geriatric APP team to recognize post discharge needs and the development, implementation and evaluation of an appropriate Plan of Care. The incumbent will make changes in response to evaluation & assessment of patient needs. The role identifies appropriate interdisciplinary services needed, coordinates those services and supervises the delivery of care.

RESPONSIBILITIES

• Conducts Comprehensive Assessments of older adults’ physical, emotional, cognitive, and social needs, including pre-surgical in-home evaluations and post-discharge follow-up, with a focus on identifying and addressing Social Determinants of Health.
• Develops and Implements Interdisciplinary Care Plans in collaboration with patients, caregivers, and healthcare teams to support recovery and independence in the least restrictive setting.
• Coordinates and Monitors Care by navigating health systems, ensuring timely services, tracking patient progress, and adjusting care plans as needed to meet individual goals.
• Responds to Health Crises and Advocates for Patients, addressing emergencies like hospitalizations and ensuring high-quality, patient-centered care aligned with individual preferences.
• Provides Leadership and Quality Oversight, including supervising care teams, mentoring new staff, documenting thoroughly, participating in quality improvement, and supporting program growth.

REQUIRED QUALIFICATIONS

• Associates Degree in Nursing
• A minimum of 2 years of nursing experience in home care, geriatric care or case management
• Registered Nurse license in New York State
• Valid NYS Driver’s License

PREFERRED ATTRIBUTES

• Master’s in Nursing: Healthcare Leadership or Geriatric NP
• Geriatric nurse case managers will work in various settings, including hospitals and patient homes. They need strong communication, organizational, and problem-solving skills to effectively support their clients
• Consistently demonstrates high standards of integrity by supporting the Rochester Regional Health Companies’ mission and values and adhering to the Corporate Code of Conduct

PHYSICAL REQUIREMENTS

Drive - Clinical - Roles in this category require frequent driving combined with mobile clinical care across settings such as emergency response, mobile clinics, and home health environments. Staff must repeatedly enter and exit vehicles, occasionally lift and carry equipment weighing up to 100 lbs. or more, and perform care within patients’ homes or other confined, unpredictable, or uncontrolled environments. These positions demand strong fine and gross motor control, firm grasping, and heightened visual and auditory awareness to ensure safe and effective care delivery. Emotional and cognitive demands are substantial due to rapid decision‑making, direct exposure to critical or sensitive situations, and independently managing patient care in the field or home setting. Environmental exposures may include traffic hazards, infectious agents, extreme temperatures, variable home conditions, and hazardous materials. Valid licensure, physical readiness, and flexibility for extended or on‑call schedules are typically required. For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements. Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

PAY RANGE

$75,712.00 - $100,880.00 (CITY: Rochester POSTAL CODE: 14607). The posted pay range is a good faith representation of potential base pay for this position. It may be modified in the future and eligible for additional pay components. Individual annual salaries/hourly rates could vary based on position details and FTE. Pay is determined by considering factors including, but not limited to, experience, relevant qualifications, specialty, internal equity, locations, and contracts.

EEO / EQUAL OPPORTUNITY STATEMENT

Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.

ABOUT ROCHSTER REGIONAL HEALTH

Rochester Regional Health is an integrated health services organization serving the people of Western New York, the Finger Lakes, St. Lawrence County, and beyond. The system includes nine hospitals; primary and specialty practices, rehabilitation centers, ambulatory campuses and immediate care facilities; innovative senior services, facilities and independent housing; a wide range of behavioral health services; and Rochester Regional Health Laboratories and ACM Global Laboratories, a global leader in patient and clinical trials. It’s vision is to lead the evolution of healthcare to enable every member of the communities it serves to enjoy a better, healthier life.