Advanced RN Case Manager

Job Summary: The Advanced RN Case Manager plays a vital role in promoting optimal social and emotional functioning, helping patients utilize healthcare and related services effectively to reach 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 to home or other care settings. Key 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 during healthcare decision-making processes. 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. Ensure system integration and continuity of care through interdisciplinary collaboration. Perform follow-up calls in accordance with Transitions of Care policies, assessing patient needs remotely and applying appropriate interventions. Offer resources before and after admission to support effective discharge planning as patient needs evolve. Conduct chemical dependency and mental health assessments and facilitate referrals to treatment. Analyze readmission trends and perform assessments to reduce hospital returns. Provide Medicare Notification Letters and assist with financial concerns by connecting patients to eligible programs. Assess and refer cases involving abuse (adult, child, sexual, domestic violence). Evaluate Social Determinants of Health and assist patients in navigating government and social service programs. Inform and assist patients with advance directives. Participate in departmental and community meetings and initiatives related to case management. 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 roles within healthcare or related fields. Licensure/Certifications: 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.

Created: 2026-03-04