RN / LPN Case Manager

Job Overview

Join our dynamic healthcare team as an RN / LPN Case Manager, where you will play a vital role in coordinating patient care across various settings. This energetic position involves assessing patient needs, developing comprehensive care plans, collaborating with multidisciplinary teams and help reduce avoidable hospital readmissions. You will be empowered to utilize your clinical expertise and case management skills to guide patients through their complex healthcare journeys.

Responsibilities

• Conduct Transitional Care Management (TCM) outreach within required regulatory timeframes.
• Review hospital, emergency department, and skilled nursing facility discharge summaries and reports.
• Perform comprehensive post-discharge assessments and medication reconciliation.
• Identify and address barriers to care, including social determinants of health.
• Work with our Care Management team to coordinate follow-up appointments with providers and specialists.
• Develop individualized care plans for high-risk and chronic disease patients.
• Educate patients and caregivers on diagnoses, medications, treatment plans, and self-management strategies.
• Collaborate with physicians, advanced practice providers, specialists, home health agencies, and community resources.
• Monitor patient progress and intervene proactively to prevent complications and readmissions.
• Document all care management activities accurately within the electronic medical record (EMR).
• Support quality initiatives, population health programs, and value-based care objectives.

Requirements

• Active Registered Nurse (RN or LPN) license in good standing.
• Minimum 3 years of clinical nursing experience.
• Strong knowledge of care coordination, transitional care management, and chronic disease management.
• Excellent communication, patient education, and organizational skills.
• Proficiency with electronic medical records (EMR/EHR) systems.
• Ability to work independently while collaborating effectively with a multidisciplinary team.
• Demonstrated knowledge of hospital medicine, medical-surgical units, behavioral health, geriatrics, pediatrics or post-acute care environments.
• Strong understanding of physiology, medical terminology, health regulation policies, and HIPAA compliance standards.

Preferred:

• Experience in primary care, case management, population health, or value-based care.
• Experience with Medicare Transitional Care Management and Chronic Care Management programs.
• Familiarity with quality metrics such as HEDIS, MIPS, and Medicare quality programs.

Join us to lead innovative patient-centered care while advancing your career in a vibrant healthcare environment dedicated to excellence!

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Work Location: In person