Hourly RN Care Manager

What You'll Do (RN Care Manager)

• Manage a small caseload of private-pay clients as the primary RN point of contact for clients and families in their homes or in Independent Living, Assisted Living, or Nursing Facilities
• Perform in-depth assessments, including medical, psychosocial, environmental, functional, legal, and family dynamics, to develop a complete picture of each client's health status and risks
• Complete and interpret clinical screening tools such as Fall Risk Assessments, Mini-Mental Status Examinations, and Depression Screenings, and incorporate findings into the care plan
• Use nursing judgment to identify safety issues, changes in condition, and gaps in care; proactively intervene and escalate when appropriate
• Develop individualized plans of care in collaboration with clients and families, focusing on safety, chronic disease management, medication oversight, independence, and quality of life
• Recommend and coordinate services such as home health, therapy, PCP and specialist follow-up, durable medical equipment, in-home support, and community resources
• Collaborate with hospitals, nursing homes, assisted living and memory care staff, physicians, and other medical providers to ensure smooth transitions of care (admission, discharge, post-hospital follow-up)
• Communicate with attorneys, financial planners, Meals on Wheels, and other community partners involved in each client's broader support system
• Perform regular home or facility visits to monitor clinical status, environment, adherence to recommendations, and overall well-being; update care plans as needs change
• Provide ongoing emotional support, education, and counseling to clients and families regarding diagnosis, prognosis, care options, and advance planning
• Offer crisis intervention and use strong critical thinking to manage urgent situations (falls, hospitalizations, sudden decline, caregiver burnout), coordinating with providers and family as needed
• Partner with the business development team to meet with prospective clients, families, and referral sources to explain RN-led care management services and benefits
• Provide back-up support to fellow Care Managers as needed
• Thoroughly document assessments, care plans, communications, and interventions; carefully track and record time spent on each client to support accurate billing and clear communication
• Participate in ongoing nursing and care management education, CE opportunities, and networking events to stay current on best practices in senior care and care coordination

Requirements

• Licensed Registered Nurse (RN) with a passion for working with older adults and their families
• Comfortable using clinical judgment in a community/field-based setting rather than in acute care
• A strong communicator who can translate medical information into clear, actionable plans for families
• Organized and self-directed, able to manage a mobile schedule, documentation, and follow-up
• A relationship-builder who enjoys collaborating with physicians, facilities, and community partners

Benefits

• Mileage reimbursement
• Company cell phone
• Computer
• Hybrid position with flexible schedule and ability to work from home when not visiting clients