Job Summary: The RN Case Manager plays a vital role in promoting optimal social and emotional functioning while helping patients effectively utilize healthcare and related services to achieve their best health outcomes. This role acknowledges the impact of psychosocial factors on recovery and focuses on patient-centered assessments and coordination of post-acute care services to ensure smooth transitions from hospital settings. Working closely with interdisciplinary teams, patients, families, and community resources, the case manager helps reduce readmissions, lower costs, and enhance patient quality of life.

Essential Responsibilities:
- Conduct discharge screenings, evaluations, and develop discharge plans, especially for patients with complex needs.
- Continuously reassess discharge plans and monitor changes in patient conditions.
- Advocate for patients alongside their support networks and healthcare teams.
- Provide interventions and emotional support to families facing healthcare decisions.
- Manage crisis interventions, adjustment to illness, and bereavement support.
- Coordinate resources such as skilled nursing facilities, home care, hospice, infusion services, long-term acute care, and durable medical equipment.
- Facilitate system integration, continuity of care, and interdisciplinary collaboration.
- Perform follow-up calls in accordance with Transitions of Care policies, assessing patient needs remotely and applying appropriate interventions.
- Offer resources before or after admission to support effective discharge planning.
- Conduct chemical dependency and mental health assessments with referrals to treatment.
- Assess readmission risks and trends.
- Provide Medicare Notification Letters.
- Assist with financial concerns by connecting patients to eligible programs and assistance.
- Evaluate and refer cases involving abuse (adult, child, sexual, domestic violence).
- Assess Social Determinants of Health and assist patients in navigating government and social service programs.
- Inform and assist with advance directives.
- Participate in departmental, hospital, and community meetings and initiatives as assigned.

Education and Experience:
- Bachelor’s Degree in Nursing from an accredited institution (must begin program within one year and complete within five years).
- Extensive experience in clinical, administrative, and managerial healthcare roles.

Licensure:
- Valid Registered Nurse license from the appropriate state board.

Work Shift: 4th Shift

This position is based in a regional healthcare setting within the Midwest United States, offering a supportive and collaborative environment focused on patient-centered care.