Senior Care RN Case Manager — Hybrid Clinic & Home Visits

TEEMA Solutions Group; Carson (CA); Hybrid; USD 104,000 - 112,000; Full time

Job summary

TEEMA Solutions Group is seeking an experienced Registered Nurse Case Manager in Carson, CA to coordinate care for frail and elderly patients across clinic, home, and virtual settings. The role focuses on case management, care coordination, and direct patient care for an assigned panel of patients.

The ideal candidate will have an accredited nursing degree, active BLS, and a minimum of two years’ experience with frail or elderly patients, plus strong assessment and communication skills.

Qualifications

• Graduate of an accredited School of Nursing
• Active BLS certification
• Minimum 2 years of nursing experience caring for frail or elderly patients in a clinical setting
• Strong clinical assessment and critical-thinking skills
• Excellent communication, organization, and care coordination abilities
• Ability to work independently and manage multiple priorities
• Comfortable conducting local home visits approximately 2–5 times per week
• Experience working with patients from diverse backgrounds
• Bilingual English/Spanish is a plus

Responsibilities

• Manage care and clinical outcomes for an assigned panel of patients.
• Complete comprehensive nursing assessments in the clinic, virtually, and during home visits.
• Develop and update individualized Plans of Care (POC).
• Educate patients and families regarding acute, chronic, and end-stage conditions.
• Identify changes in patient condition and appropriately escalating concerns to the PCP.
• Coordinate complex care and transitions between hospitals, emergency departments, skilled nursing facilities, hospice, and home settings.
• Help prevent avoidable hospitalizations through proactive care coordination and follow-up.
• Coordinate services including specialists, labs, procedures, personal care, dental, vision, and transportation.
• Partner with PCPs to process medical orders, review results, and coordinate follow-up care.
• Perform nursing procedures and direct clinical care as ordered.
• Maintain accurate and timely documentation within the Electronic Health Record (EHR).
• Collaborate closely with patients, families, physicians, and the interdisciplinary care team.

Skills

Case management

Care coordination

Clinical assessment

Direct patient care

Education

Graduate of an accredited School of Nursing

Job description

TEEMA Solutions Group is seeking an experienced Registered Nurse Case Manager in Carson, CA to coordinate care for frail and elderly patients across clinic, home, and virtual settings. The role focuses on case management, care coordination, and direct patient care for an assigned panel of patients.

The ideal candidate will have an accredited nursing degree, active BLS, and a minimum of two years’ experience with frail or elderly patients, plus strong assessment and communication skills.