Registered Nurse Case Manager

Overview

• Provide telephonic clinical outreach to support safe transitions of care.
• Focus on reducing readmissions and improving patient outcomes through assessment and education.
• Collaborate with interdisciplinary teams to ensure continuity of care.
• Support value-based care objectives by enhancing utilization outcomes.
• Utilize evidence-based models to align with organizational protocols.
• Maintain professional nursing standards and active licensure.
• Participate in quality improvement initiatives to enhance care effectiveness.
• Document interventions and outcomes in designated care management platforms.

Key Responsibilities & Duties

• Conduct post-discharge telephonic outreach to identify risks and needs.
• Perform medication reconciliation and reinforce discharge instructions.
• Educate patients on symptom monitoring and self-management strategies.
• Coordinate follow-up appointments with healthcare providers.
• Monitor admission feeds to identify care transition opportunities.
• Escalate clinical concerns and social barriers to care teams.
• Facilitate referrals to community resources to address patient needs.
• Support closure of quality gaps related to medication adherence and follow-up.

Job Requirements

• Active Registered Nurse (RN) license required; NLC license preferred.
• Bachelor of Science in Nursing (BSN) required.
• Minimum 2 years of clinical nursing experience; 3 years preferred.
• Experience in care management, transitions of care, or case management preferred.
• Proficiency with EHRs and care management systems.
• Strong clinical assessment and critical thinking skills.
• Excellent communication and patient education abilities.
• Ability to manage priorities in a remote environment.