RN Case Manager - Home Health

Schedule: Monday–Friday | 8:00 AM – 4:30 PM

We are seeking a compassionate and highly organized Case Manager to join our team and play a critical role in coordinating patient care across the continuum. In this role, you will partner with patients, families, and an interdisciplinary healthcare team to ensure safe, efficient, and high-quality care from admission through discharge and beyond.

This is an ideal opportunity for a clinician who thrives in a collaborative environment, enjoys problem-solving, and is passionate about advocating for patients and improving outcomes.

• Conduct comprehensive patient assessments, including clinical, psychosocial, functional, and financial needs

• Develop and manage individualized care plans in collaboration with physicians, nurses, therapists, and social services

• Coordinate transitions of care (hospital to home, rehab, or long-term care) to ensure continuity and safety

• Partner with insurance providers to secure authorizations and ensure appropriate utilization of services

• Identify and remove barriers to discharge, including social, financial, and logistical challenges

• Serve as a patient advocate, ensuring needs and preferences are represented in care decisions

• Educate patients and families on diagnoses, treatment plans, and post-discharge care

• Connect patients with community resources, support services, and post-acute providers

• Facilitate referrals to specialized services such as housing, behavioral health, and legal resources

• Monitor patient progress, adjust care plans, and track outcomes and quality metrics

• Maintain accurate, timely documentation of assessments, interventions, and care plans

• Participate in interdisciplinary rounds and care conferences

Required:

• Active Oregon RN License or degree in Social Work, Nursing, or related healthcare field

• Clinical experience in acute care or home health

• Strong care coordination, discharge planning, or patient assessment experience

• Excellent communication and collaboration skills

Preferred:

• BSN or MSN

• Case Management Certification (CCM or equivalent)

• Experience with discharge planning or case management

• Bilingual (English/Spanish)