Registered Nurse Case Manager

Position Summary

We are seeking an experienced and compassionate Registered Nurse (RN) Case Manager to join our home health team. The Case Manager will be responsible for coordinating and overseeing the delivery of safe, effective, and patient-centered home health services while also providing clinical leadership and administrative support.

This position combines hands-on skilled nursing, patient case management, staff supervision, care coordination, quality oversight, and administrative responsibilities. The ideal candidate is an organized, clinically experienced RN who understands the unique needs of patients receiving care in their homes and is comfortable working with patients, families, physicians, caregivers, and interdisciplinary team members.

The Case Manager will ensure that patient care is delivered in accordance with the individualized plan of care, physician orders, applicable federal and Virginia requirements, Medicare/Medicaid guidelines, and agency policies and procedures.

Key Responsibilities

Patient Care & Case Management

• Conduct comprehensive initial and ongoing assessments of patients, including OASIS assessments as required.
• Coordinate the admission, recertification, resumption of care, transfer, and discharge processes.
• Develop, implement, monitor, and update individualized patient plans of care.
• Coordinate nursing, therapy, home health aide, social work, and other services based on patient needs.
• Monitor patients' conditions and identify changes requiring physician notification or modification of the plan of care.
• Consult with physicians and other healthcare professionals regarding patient treatment and changes in condition.
• Coordinate referrals and facilitate continuity of care with physicians, hospitals, facilities, and community providers.
• Participate in case conferences and interdisciplinary care planning.
• Provide skilled nursing services when assigned or clinically necessary.
• Educate patients and caregivers regarding medications, disease management, treatment plans, safety, preventive care, and appropriate use of healthcare resources.
• Participate in discharge planning and ensure appropriate transition of care.
• Supervise and evaluate home health aides and other assigned clinical personnel in accordance with agency policy and applicable requirements.
• Provide guidance and clinical support to LPNs and other nursing personnel.
• Ensure patient needs are continually assessed and that services remain appropriate to those needs.

Clinical Leadership & Supervision

• Provide clinical direction and support to nursing and paraprofessional staff.
• Assist with making patient and personnel assignments.
• Ensure appropriate clinical coverage and staff supervision during assigned operating/service hours.
• Evaluate the quality and effectiveness of services provided by field personnel.
• Assist with orientation, competency assessment, in-service education, and continuing education.
• Identify staff development needs and promote professional growth.
• Communicate agency policies, procedures, clinical expectations, and regulatory requirements to staff.
• Assist with the development and maintenance of clinical policies and procedures.
• Promote safe, effective, patient-centered care throughout the organization.
• Participate in performance improvement, QAPI/CQI, utilization review, and clinical record review activities.
• Assist with corrective action plans and follow-up when clinical or operational deficiencies are identified.

Documentation & Regulatory Compliance

• Maintain timely, accurate, and complete clinical documentation.
• Review clinical records for completeness, accuracy, and compliance with agency requirements.
• Ensure documentation supports the services provided and the patient's plan of care.
• Maintain working knowledge of Medicare, Medicaid, federal, Virginia, and accreditation requirements applicable to home health.
• Assist with maintaining compliance with applicable licensure, certification, and accreditation standards.
• Participate in agency surveys, audits, record reviews, and quality improvement activities as requested.
• Protect the confidentiality and security of patient, personnel, and agency information in accordance with HIPAA and agency policies.

Administrative & Agency Responsibilities

• Work closely with the Administrator and clinical leadership to coordinate daily operations and patient care services.
• Assist with planning, organizing, directing, and evaluating clinical programs and services.
• Assist with identifying community healthcare needs and developing services to address those needs.
• Communicate patient care needs, staffing needs, operational concerns, and clinical trends to agency leadership.
• Participate in development and implementation of agency goals, policies, procedures, and programs.
• Assist with staff interviews, orientation, training, and performance evaluations as assigned.
• Participate in professional meetings, conferences, workshops, and community activities.
• Assist with maintaining positive relationships with physicians, hospitals, facilities, referral sources, patients, families, and community organizations.
• Assist with marketing and community relations activities when appropriate.
• Participate in emergency preparedness and agency response activities as assigned.
• Promote a culture of quality, accountability, teamwork, and compassionate patient care.

Qualifications

Required:

• Current, unrestricted Registered Nurse (RN) license in the Commonwealth of Virginia.
• Graduate of an accredited nursing program.
• Minimum of 2 years of home health experience.
• Minimum of 1 year of administrative or supervisory experience in home health or a related healthcare setting.
• Current CPR certification; in-person/hands-on certification required if applicable under agency policy.
• Working knowledge of Medicare and Medicaid home health requirements.
• Working knowledge of OASIS, home health documentation, care planning, and clinical compliance requirements.
• Valid driver's license, reliable transportation, and willingness to travel to patients' homes.
• Ability to pass required background screening.
• Strong written and verbal communication skills in English.
• Strong organizational, leadership, time-management, and problem-solving skills.

Preferred Qualifications

• Previous experience as a Home Health Case Manager, Clinical Manager, Director of Nursing, or similar leadership role.
• Experience with OASIS and Medicare-certified home health.
• Experience with QAPI/CQI, utilization review, clinical record review, and regulatory surveys.
• Experience supervising RNs, LPNs, HHAs, or other interdisciplinary personnel.
• Familiarity with electronic medical records and home health software.

Physical & Job Requirements

• Ability to travel to patients' homes within the agency's service area.
• Ability to enter and work safely in a variety of home environments, including homes that may not be routinely wheelchair accessible.
• Ability to sit, stand, walk, stoop, bend, and perform other activities associated with patient assessment and home visits.
• Ability to perform and demonstrate appropriate nursing procedures.
• Ability to assist with or safely manage patient mobility and repositioning within the scope of the RN's duties and agency policies.
• Ability to communicate effectively by telephone, electronically, and in person.
• Ability to read clinical and administrative documents and accurately complete required documentation.
• Position includes both field and office/administrative responsibilities.
• Occasional travel for meetings, conferences, training, or other agency activities may be required.

Why Join Our Team?

• Meaningful work providing care to patients in the comfort of their homes.
• Opportunity to combine clinical nursing with leadership and case management.
• Supportive interdisciplinary team environment.
• Professional development and continuing education opportunities.
• Opportunity to make a direct impact on patient outcomes and quality of care.

Join us to be part of a passionate team committed to delivering exceptional patient-centered care through innovative case management practices!

Pay: $86,218.98 - $103,833.62 per year

Benefits:

• Paid sick time
• Paid time off
• Referral program

Education:

• Bachelor's (Preferred)

Experience:

• Supervisory: 1 year (Required)
• Home health: 2 years (Required)

License/Certification:

• RN License (Required)
• CPR Certification (Required)

Ability to Commute:

• Fredericksburg, VA 22405 (Required)

Work Location: In person