Nurse - Case Manager

Job Summary:
The Experienced RN Case Manager is responsible for assessing, planning, coordinating, implementing, and evaluating patient care plans. This role collaborates with physicians, interdisciplinary teams, patients, families, and community resources to promote positive patient outcomes, reduce hospital readmissions, and ensure efficient utilization of healthcare services.

Key Responsibilities
Conduct comprehensive patient assessments to identify medical, psychosocial, and discharge planning needs.
Develop, implement, and monitor individualized care plans.
Coordinate care across multiple healthcare settings, including hospitals, outpatient clinics, rehabilitation facilities, home health, and long-term care.
Collaborate with physicians, nurses, therapists, social workers, and other healthcare professionals to ensure continuity of care.
Facilitate safe and timely discharge planning and transition of care.
Educate patients and families regarding diagnoses, treatment plans, medications, disease management, and available community resources.
Monitor patient progress and modify care plans as needed.
Perform utilization review to ensure appropriate level of care and compliance with payer guidelines.
Maintain accurate and timely documentation in the electronic medical record (EMR).
Ensure compliance with federal, state, accreditation, and organizational regulations.
Advocate for patients while balancing quality, safety, and cost-effective care.
Participate in quality improvement initiatives aimed at reducing readmissions and improving patient outcomes.