RN Case Manager

Jobtailor

Pennsylvania

On-site

USD 65,000 - 90,000

Full time

14 days+

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Job summary

Jobtailor is seeking a registered nurse to provide in-house, facility, telephonic, and home visits to high-risk patients, aiming to prevent hospital admissions and readmissions. You will perform care-plan development, assessments, discharge reviews, and supervise LPNs within a Complex Care Team.

The role requires a valid RN license, 2+ years clinical experience, and CCM certification is a plus. Travel up to 10% and BLS within 90 days are part of the job, with strong teamwork and communication

Qualifications

Associate degree in Nursing required.
RN license in the state of employment required.
Minimum 2 years of clinical work experience required.
Minimum 1 year of community case-management experience highly desired.
BSN preferred.
Compact nursing license preferred where available.
CCM or CCMC/CMCN certification desired.
Current, valid driver's license required.
BLS certification within 90 days of employment.

Responsibilities

Provide in-house, facility, telephonic, and home visits to high-risk patients to prevent unnecessary hospital admissions and readmissions.
Perform field nursing interventions, patient assessments, care-plan development, clinical assessments, fall-prevention assessments, social-determinants-of-health screenings, medication monitoring, health education, and self-care instruction.
Conduct initial case-management assessments, obtain patient consent, and coordinate individualized plans of care with patients, caregivers, PCPs, and care-team members.
Review charts and conduct final patient discharge; obtain formal approval from the Complex Care Leadership Team when required.
Conduct supervisory visits with LPNs and patients, providing education and overseeing appropriate discharge.
Coordinate multidisciplinary team meetings, report and document care activities, and follow up on action items.
Help patients navigate healthcare systems and connect them with community, social, and financial resources.
Coordinate service delivery, facilitate use of natural supports and community resources, and maintain communication with families and community providers.
Establish supportive relationships that promote patient self-management.
Monitor the quality, frequency, and appropriateness of HHA visits and other outpatient services.
Collaborate with Complex Care and Clinical Strategy Team members, including Hospital Care Managers and Post Hospital Care Coordinators and Managers, to ensure holistic care.
Provide urgent home visits under PCP direction to prevent unnecessary hospital admissions.
Provide clinical supervision and serve as a clinical lead for the Complex Care Team.
Perform other duties as assigned by the manager.

Skills

Patient assessment

Care plan development

Clinical supervision

Medication monitoring

Fall prevention

SDOH screening

Documentation

Community health knowledge

Nursing theory

Organizing

Autonomy

Interpersonal skills

Communication

Critical thinking

Education

Associate degree in Nursing

Bachelor's Degree in Nursing

Tools

Microsoft Office

Excel

Word

PowerPoint

Outlook

Job description

Provide in-house, facility, telephonic, and home visits to high-risk patients to prevent unnecessary hospital admissions and readmissions
Perform field nursing interventions, patient assessments, care-plan development, clinical assessments, fall-prevention assessments, social-determinants-of-health screenings, medication monitoring, health education, and self-care instruction
Conduct initial case-management assessments, obtain patient consent, and coordinate individualized plans of care with patients, caregivers, PCPs, and care-team members
Review charts and conduct final patient discharge; obtain formal approval from the Complex Care Leadership Team when required
Conduct supervisory visits with LPNs and patients, providing education and overseeing appropriate discharge
Coordinate multidisciplinary team meetings, report and document care activities, and follow up on action items
Help patients navigate healthcare systems and connect them with community, social, and financial resources
Coordinate service delivery, facilitate use of natural supports and community resources, and maintain communication with families and community providers
Establish supportive relationships that promote patient self-management
Monitor the quality, frequency, and appropriateness of HHA visits and other outpatient services
Collaborate with Complex Care and Clinical Strategy Team members, including Hospital Care Managers and Post Hospital Care Coordinators and Managers, to ensure holistic care
Provide urgent home visits under PCP direction to prevent unnecessary hospital admissions
Provide clinical supervision and serve as a clinical lead for the Complex Care Team
Perform other duties as assigned by the manager

Requirements

Associate degree in Nursing required
Valid, active Registered Nurse (RN) license in the state of employment required
Minimum 2 years of clinical work experience required
Minimum 1 year of community case-management experience highly desired
Bachelor's Degree in Nursing (BSN) or RN with a bachelor's degree in a related clinical field preferred
Compact nursing license preferred where available
Certified Case Manager certification through CCMC or CMCN desired/preferred
Current, valid driver's license required and must be maintained
Basic Life Support (BLS) certification from the American Heart Association or American Red Cross required within the first 90 days of employment
Strong interpersonal and communication skills
Critical-thinking skills
Ability to work autonomously
Ability to monitor, assess, and record patient progress and adjust plans accordingly
Ability to plan, implement, and evaluate individual patient care plans
Knowledge of nursing and case-management theory and practice
Knowledge of patient-care charts and patient histories
Knowledge of clinical and social-services documentation procedures and standards
Knowledge of community health and social-services support agencies and networks
Organizing and coordinating skills
Ability to communicate technical information to non-technical personnel
Proficiency in Microsoft Office Suite, including Excel, Word, PowerPoint, and Outlook
Ability and willingness to travel locally, regionally, and nationwide up to 10% of the time
Spoken and written fluency in English
Independent judgment required

Demonstrates expertise in nursing and case management, with a focus on patient assessments, care plan development, and coordination of multidisciplinary care. Proficient in navigating healthcare systems and connecting patients with community resources while ensuring quality patient care.

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