RN Case Manager - Care Ally

Great Lakes Physician Administrative Services LLC; United States; On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Comprehensive health benefits (medical

Dental and vision benefits

Mental health benefit

Life and disability insurance

Tuition reimbursement

Immediate 401(k) match

Volunteer time off (40 hours)

Parental leave up to 12 weeks at 100%

Adoption/surrogacy assistance for non-

Job summary

The South Bend Clinic is seeking an experienced Registered Nurse to join the VBC Operations team on Eddy Street Campus in South Bend, IN. The role focuses on care management, utilization management, and patient education to coordinate comprehensive care plans across multidisciplinary teams.

Responsibilities include developing care plans with physicians, educating patients, and ensuring timely access to services while maintaining HIPAA guidelines. Local travel may be required occasionally.

Qualifications

• Unencumbered RN license required in Indiana.
• Experience in case management or care management preferred (CERTIFIED CASE MANAGER a plus).
• Experience with Medicare/Medicaid programs.
• Experience with multiple EHR/EMR systems.
• Ability to collaborate with staff across offices.
• Strong multitasking, time management, and communication skills.

Responsibilities

• Plan and implement educational needs of assigned patients with the care team.
• Coordinate clinical care plans with primary care providers and team members; communicate plans to patients and families.
• Enroll patients in CCM program and review services with patients.
• Execute electronic care plans and assess patient health and education needs from calls and records.
• Maintain ongoing patient communication, with monthly check-ins of at least 20 minutes.
• Collaborate with providers to facilitate appropriate physical, behavioral, and social services.
• Review and adjust care plans to meet patient needs; address complex clinical situations efficiently.
• Gather information and coordinate referrals to social workers for complex social issues.

Education

Registered Nurse license (Indiana)

Tools

EHR/EMR systems

Job description

Department: VBC Operations Location: Eddy Street Campus - 211 N. Eddy Street, South Bend, IN 46617 Hours: 40 Hours Weekly | Monday-Friday

At The South Bend Clinic, you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician-led team that works as one and puts patients at the center of everything we do. With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high-quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve.

Benefits

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

Responsibilities

Patient Care / Patient Education

Assumes an active role in the planning and implementing educational needs of assigned patients, with direct care team and need consultants: Diabetic Educator, pharmacy, dietary, wound care, etc.

Coordinates assigned patients' clinical care plan in conjunction with the Primary Care Provider and with appropriate team members and communicates the plan to patient/family in a timely manner.

Review services with interested patients and assist in enrolling them in the CCM program

Provide all services necessary in order to execute an electronic care plan

Determine an individual’s health and educational needs as a result of inbound and outbound phone calls, and review of medical records with patients

Maintain communication with patients to measure no less than 20 minutes per month

Collaborate with the patient's provider to facilitate appropriate physical, behavioral and social services

Review care plans and make changes as necessary

Provide patients with information regarding medical questions/concerns

Examples of CM activities may include educating newly diagnosed patients about the disease and treatments; managing therapies; and drug administration and side effects

Care Facilitation

Develops, manages, and drives clinical plan of care with physician and multi-disciplinary care team. Works collaboratively and maintains active communication with physicians, nursing and other care team members to ensure timely patient management and facilitation of services.

Coordinates patient care across the care continuum to reduce fragmentation of care and addresses/ resolves system issues that may be impeding progress and quality of care for patients.

Focuses on management of the complex patient with the goal of patient self-management, quality outcomes, and resource utilization goals.

Identifies and refers patients for social worker intervention, as well as transitions of care follow up at home.

Addresses complex clinical situations efficiently, to avoid unnecessary delays in care.

Obtains the support of the social worker for complex social issues, behavioral problems, home and family issues, placements, guardianship, hospice, palliative care referrals, drug and alcohol abuse, and violence.

Utilization Management

Communicates with physicians and nursing regarding resource utilization, LOS, level of care, and post-acute care needs daily. Coordinates with post-acute partners and facilities to ensure efficient care and patient-centered transitions.

General Responsibilities

Exhibits computer systems knowledge and proficiency as necessary to perform job functions. Demonstrates the attitudes and behaviors of The South Bend Clinic Service Standards. Performs other duties as assigned when appropriate. Adheres to HIPAA guidelines set forth in Clinic policies and procedures.

POSITION REQUIREMENTS

Education/Certification/License:

Minimum of an unencumbered license as a Registered Nurse in the state of Indiana.

Knowledge, Skills, and Abilities:

• Must have experience in case management or care management (Certified Case Manager preferred)
• Must have experience with Medicare/Medicaid
• Experience with multiple EHR/EMR systems
• Ability to work collegially with staff members from multiple offices
• Ability to manage multiple patients simultaneously
• Ability to build and maintain relationships with patients, families and client providers
• A background in geriatric care, family medicine and/or long-term care (skilled nursing, home health, hospice, public health, assisted living) highly preferred.
• A background and ability to work with populations with special needs
• Competence and experience with electronic charting
• Ability to multitask
• Excellent written and verbal communication skills.
• Self-directed with the ability to work independently and in groups
• Exceptional time management skills, with a high level of individual initiative
• Detail oriented with strong organizational, planning, and problem solving skills
• Can be depended upon to effectively plan and organize multiple assignments to ensure workload’s completion, yet flexible enough to handle changing schedules

Special Demands/Requirements:

Occasional, local travel may be required for off-site meetings.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person. Let’s start with what matters. People. Purpose. Care. At the South Bend Clinic, we believe healthcare works best when it’s personal, connected, and led by people who truly care. We are a physician-led medical group built on trusted relationships, teamwork, and a shared commitment to putting patients first in every decision we make. Our team members are caregivers, collaborators, problem-solvers, and leaders. Together, we show up with compassion, act with purpose, and take ownership of the care we deliver and the experience we create. Whether you’re caring directly for patients or supporting the teams who do, your role matters here, and your voice is valued. We listen with intention, work as one, and challenge ourselves to keep improving, not for recognition, but because our patients, families, and communities count on us. Innovation at SBC isn’t about chasing what’s next for its own sake. It’s about finding better ways to deliver high-quality, affordable, and accessible care, today and into the future. If you’re looking for meaningful work, supportive teammates, and the opportunity to help shape the future of care while staying grounded in compassion and community, you’ll find your place at the South Bend Clinic.