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Case Manager Registered Nurse (RN)

Department: Care Coordination
Location: Remote with travel throughout assigned service area
Reports To: Care Coordination Supervisor

Position Summary

Sequoia Integrative Medical Services is seeking a compassionate, organized, and patient-focused Registered Nurse (RN) to join our Care Coordination team. The Case Manager RN plays a vital role in coordinating care for patients across the healthcare continuum, ensuring they receive the resources, education, and support needed to achieve optimal health outcomes.

This position works collaboratively with providers, facilities, patients, families, and community partners to improve continuity of care, reduce hospitalizations, and promote patient independence. The ideal candidate is an experienced nurse with strong critical thinking skills, exceptional communication abilities, and a passion for improving the lives of geriatric and medically complex patients.

Essential Responsibilities

Care Coordination & Case Management

• Conduct comprehensive patient assessments, including medical history, psychosocial needs, functional status, and barriers to care.
• Develop individualized, patient-centered care plans in collaboration with providers, patients, caregivers, and interdisciplinary team members.
• Coordinate services including home health, rehabilitation, specialty referrals, durable medical equipment (DME), hospice, and community resources.
• Facilitate smooth transitions of care following hospitalizations, emergency department visits, skilled nursing stays, or rehabilitation admissions.
• Monitor patients with chronic and complex medical conditions to promote improved health outcomes and prevent avoidable hospitalizations.

Patient Advocacy

• Serve as a patient advocate by identifying and addressing barriers to care, including transportation, financial concerns, medication access, and social determinants of health.
• Connect patients and families with appropriate community resources and support services.
• Assist patients in navigating the healthcare system and coordinating follow-up appointments.

Monitoring & Follow-Up

• Complete timely follow-up calls after hospital discharge and significant healthcare events.
• Monitor patient progress toward established goals and adjust care plans as clinical needs change.
• Collaborate with providers regarding changes in patient condition and recommend appropriate interventions.

Interdisciplinary Collaboration

• Partner with physicians, nurse practitioners, nurses, therapists, social workers, facility staff, and other healthcare professionals to coordinate comprehensive patient care.
• Participate in interdisciplinary case conferences and quality improvement initiatives.
• Communicate effectively with patients, caregivers, healthcare facilities, and community organizations.

Patient & Family Education

• Educate patients and caregivers regarding diagnoses, medications, treatment plans, disease management, and preventive care.
• Encourage self-management strategies that improve quality of life and support long-term health goals.
• Provide education regarding available healthcare and community resources.

Documentation & Compliance

• Maintain accurate, timely, and complete documentation within the Electronic Health Record (EHR).
• Ensure compliance with HIPAA, Medicare regulations, organizational policies, and applicable state and federal requirements.
• Assist with quality initiatives and performance improvement projects.

Professional Development

• Maintain current nursing licensure and required certifications.
• Participate in continuing education and ongoing professional development.
• Stay current with evidence-based practices in case management and care coordination.

Qualifications

Education

• Associate or bachelor's degree in nursing (BSN preferred)
• Current unrestricted Wisconsin Registered Nurse (RN) license
• Case Management Certification (CCM, ACM, or equivalent) preferred but not required

Experience

• Minimum one year of Registered Nurse experience required
• Previous experience in case management, care coordination, discharge planning, home health, hospice, primary care, geriatrics, or chronic disease management preferred
• Experience utilizing Electronic Health Record (EHR) systems
• Knowledge of Medicare, managed care, and community resources preferred

Knowledge, Skills & Abilities

• Strong clinical assessment and critical thinking skills
• Excellent organizational and time management abilities
• Ability to prioritize multiple patients and changing clinical needs
• Exceptional communication and interpersonal skills
• Ability to work independently while collaborating effectively within a multidisciplinary team
• Strong patient education and motivational interviewing skills
• Proficiency with Microsoft Office and Electronic Health Records
• Commitment to compassionate, patient-centered care

Working Conditions

• Remote position with routine travel throughout assigned service area
• Regular travel to hospitals, skilled nursing facilities, assisted living communities, and patient care locations
• Valid driver's license, reliable transportation, and proof of automobile insurance required
• Occasional lifting of up to 25 pounds
• Ability to sit, stand, walk, and travel throughout the workday

Benefits

Sequoia Integrative Medical Services offers a competitive compensation and benefits package, which may include:

• Competitive salary
• Paid Time Off (PTO)
• Health Insurance Stipend
• Mileage reimbursement
• Continuing education opportunities
• Supportive and collaborative team environment
• Opportunities for professional growth and advancement

Key Performance Indicators (KPIs)

Success in this role will be measured by:

• Reduction in avoidable emergency department visits and hospital readmissions
• Timely completion of patient assessments and follow-up activities
• Achievement of patient care plan goals
• Patient and family satisfaction
• Quality and accuracy of clinical documentation
• Compliance with organizational, state, and federal standards
• Effective collaboration with providers, facilities, and interdisciplinary teams