Advanced RN Case Manager

Job Summary: The role of the Advanced RN Case Manager is to support patients in achieving their best possible health outcomes by facilitating appropriate use of healthcare and community services. This position emphasizes the connection between psychosocial factors and recovery, ensuring smooth transitions from hospital care through comprehensive patient-centered assessments and coordination of post-acute services. 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 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 line with Transitions of Care Discharge Policy, assessing patient needs remotely and applying appropriate interventions. Offer resources to patients before or after admission to facilitate effective discharge planning as needs evolve. Conduct chemical dependency and mental health assessments and refer patients to treatment as needed. 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, including adult, child, sexual, and 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, hospital, and community meetings and initiatives relevant to the role. Education and Experience: Bachelor's Degree in Nursing from an accredited institution (must begin program within one year and complete within five years if not already obtained). Extensive experience in clinical, administrative, and managerial healthcare roles. Licensure/Certifications: Registered Nurse license valid in the relevant state. Work Shift: First shift, full-time, 40 hours per week. This position is based in a regional healthcare setting within the Midwest United States.

Created: 2026-03-10