Senior Care RN Case Manager (Hybrid Clinic/Field)

TEEMA; Carson (CA); Hybrid; USD 85,000 - 110,000; Full time

Job summary

TEEMA is seeking a dedicated Registered Nurse Case Manager to join our senior care team in a hybrid Carson, CA setting. The role focuses on ownership of care outcomes for an assigned patient panel, collaborating with PCPs and an interdisciplinary team to deliver value-based care in clinic, virtual, and home environments.

Responsibilities include comprehensive assessments, care planning, transitions, and direct nursing interventions.

Qualifications

• Graduate of an accredited School of Nursing.
• Active, unencumbered Registered Nurse (RN) License.
• Active Basic Life Support (BLS) certification.

Responsibilities

• Take ownership of care outcomes for an assigned patient panel, in partnership with PCPs.
• Conduct clinical assessments (at least every six months) in clinic, virtually, or at home.
• Develop and update Plans of Care with input from patients, families, and POA representatives.
• Educate patients and support networks on managing acute, chronic, and end-stage conditions.
• Coordinate care across hospitals, SNFs, and home settings to prevent hospitalizations.
• Facilitate transitions in and out of hospice and monitor census with hospice agencies.
• Act as primary care coordinator for services, orders, tests, and referrals.
• Perform nursing procedures and direct care in clinic or home visits.
• Document assessments and actions in EHR timely and accurately.
• Support clinic operations with coordinating tasks.

Skills

Nursing Assessment

Care Coordination

Clinical Documentation

Patient Advocacy

Home Visits

Communication

Bilingual English/Spanish

Education

RN License

BLS Certification

Tools

EHR Systems

Telehealth Platforms

Job description

TEEMA is seeking a dedicated Registered Nurse Case Manager to join our senior care team in a hybrid Carson, CA setting. The role focuses on ownership of care outcomes for an assigned patient panel, collaborating with PCPs and an interdisciplinary team to deliver value-based care in clinic, virtual, and home environments.

Responsibilities include comprehensive assessments, care planning, transitions, and direct nursing interventions.