Nurse Case Manager (RN/LPN)

The RN/LPN Discharge Nurse plays a vital role in coordinating the safe and efficient discharge of residents from our facility, ensuring continuity of care and facilitating transitions to home or other care settings. This position requires strong clinical skills, excellent communication abilities, and a commitment to exceptional resident care.

Schedule: Full-Time, Weekdays, Day Shift, 8 Hour Shifts

Primary Responsibilities and Duties:

• Coordinate the discharge planning process for residents, working closely with the resident’s healthcare team, including physicians, therapists, social workers, and family members.
• Conduct comprehensive assessments of residents’ discharge needs, including medication reconciliation, equipment requirements, and post-discharge care arrangements.
• Collaborate with residents, families, and caregivers to develop individualized discharge plans that meet their preferences, goals and clinical needs.
• Provide education and instructions to residents and their families regarding patient care, medications, follow-up appointments, and other necessary information.
• Communication effectively with community resources, home health agencies, durable medical equipment providers, and other healthcare professionals to coordinate services and ensure a smooth transition for residents.
• Coordinate transportation arrangements for residents’ discharge, ensuring that transportation services are arranged and available as needed.
• Complete discharge paperwork accurately and ensure all required documentation is obtained, including discharge summaries, medication lists, and follow-up care instructions.
• Monitor residents’ condition and progress during the discharge process, intervening as needed to address any concerns or complications. Collaborate with the Director of Nursing and other members of the healthcare team to ensure compliance with regulator requirements and facility policies related to discharge planning and documentation.
• Participate in team meetings to discuss discharge plans, resident progress, and any barriers to discharge.
• Perform all other duties assigned.

Job Qualifications:

• Valid Registered Nurse License (RN) or Licensed Practical Nurse License (LPN) in the state where work is performed.
• Some experience in discharge planning or care coordination roles within a healthcare setting required.
• Some previous case management experience preferred.
• Knowledge of community resources and support services available to older adults.
• Knowledge of medical terminology, charting skills, and familiarity with a skilled nursing facility.
• Strong written and verbal communication skills.
• Basic knowledge of Microsoft Office applications and operating computer hardware and software.
• Ability to build rapport with patients through a compassionate and caring demeanor.

Physical Requirements:

• Work performed in a medical setting due to the need to work in person with residents and their families.
• Ability to work in a variety of environments within the facility, including resident rooms, common areas, and administrative offices.
• Must be able to sit, stand, bend, reach, talk, hear, stoop, kneel, crouch, stretch, twist, use hands and fingers, handle or operate objects, equipment, or controls.
• Required vision includes close, vision, distance, peripheral, and the ability to adjust focus.
• Emotional resilience and ability to cope with the physical and emotional demands of working with residents who may have complex healthcare needs.
• Stamina to stand and move about the facility to perform frequent rounds and respond to emergent situations as needed.
• Capability to lift and/or assist other nursing staff in transferring residents safely, with proper body mechanics and assistance as needed.
• Maintain regular attendance and timeliness as set forth within the work schedule designated by the department supervisor/manager.
• The ability to exert maximum muscle force to lift, push, pull, or carry objects.

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