The RN Case Manager provides clinical case management and care coordination for an assigned population of residents within a senior living community. The position completes comprehensive nursing assessments, identifies resident needs and risks, develops and monitors individualized plans of care, and coordinates services across internal departments, healthcare providers, residents, and families.
This role serves as a clinical resource throughout the resident's continuum of care, including changes in condition, transitions between care settings, hospitalizations, rehabilitation stays, and return to the community. The position promotes resident safety, quality outcomes, regulatory compliance, and continuity of care while supporting residents' independence, preferences, and overall well-being.
Primary responsibilities: - Completes comprehensive nursing assessments and reassessments to identify residents' clinical, functional, psychosocial, and safety needs.
- Develops, implements, evaluates, and updates individualized nursing care plans in collaboration with residents, families, physicians, interdisciplinary team members, and external providers.
- Manages an assigned resident caseload and coordinates healthcare services, treatments, referrals, appointments, therapies, diagnostic testing, and other clinical interventions.
- Monitors residents for changes in condition, evaluates clinical findings, initiates appropriate nursing interventions, and communicates or escalates concerns to physicians and other authorized providers.
- Coordinates transitions of care, including admissions, hospital transfers, rehabilitation stays, changes in level of care, and returns to the community.
- Reviews physician orders, medication regimens, treatment plans, laboratory results, and clinical documentation to support accuracy, continuity, and timely follow-up.
- Facilitates interdisciplinary care conferences and communicates with residents and authorized representatives regarding clinical status, care needs, treatment recommendations, and available services.
- Provides clinical education and guidance to residents, families, caregivers, and team members regarding health conditions, medications, treatments, preventive care, and changes in condition.
- Collaborates with community leadership and clinical teams to identify resident risks, reduce avoidable hospitalizations, address care gaps, and improve resident outcomes.
- Maintains accurate, timely, and confidential clinical records in accordance with professional nursing standards, organizational requirements, and applicable laws and regulations.
- Participates in quality assurance, infection prevention, incident review, risk-management, and performance-improvement activities related to resident care and clinical services.
- Serves as a clinical resource to team members and provides direction, consultation, or nursing delegation within the RN scope of practice and organizational policy.
- Supports emergency response and provides direct nursing intervention when clinically necessary, while maintaining primary accountability for case management and care coordination responsibilities.
- Maintains current knowledge of professional nursing standards, applicable regulations, organizational policies, and evidence-informed practices relevant to senior living and care management.
To be successful in this role, you should have the following: - Graduate of an accredited registered nursing program.
- Current, active Registered Nurse license in the state of employment, in good standing and without restriction.
- Two years of professional nursing experience in senior living, assisted living, skilled nursing, home health, hospital care, care management, or a related clinical setting.
- Experience conducting nursing assessments, developing care plans, coordinating services, and communicating with physicians and interdisciplinary care teams.
- Current CPR or Basic Life Support certification, as required by the community or applicable regulation.
- Knowledge of professional nursing standards, resident rights, confidentiality requirements, infection-prevention practices, and applicable healthcare regulations.
- Demonstrated ability to evaluate clinical information, establish priorities, exercise independent nursing judgment, and respond appropriately to changes in condition.
- Effective written, verbal, organizational, documentation, and interpersonal skills.
- Ability to use electronic health records, clinical documentation systems, and standard workplace technology.
- Ability to maintain required licensure, certifications, screenings, and continuing-education requirements.
Preferred qualifications:
- Bachelor of Science in Nursing.
- Three or more years of nursing experience with older adults or medically complex populations.
- Experience in senior living, life plan communities, assisted living, memory support, home- and community-based services, or post-acute care.
- Experience in case management, utilization management, transitions of care, population health, or chronic-condition management.
- Certified Case Manager certification or another relevant care-management credential.
- Experience with quality improvement, regulatory surveys, risk management, or interdisciplinary clinical programs.
Working Conditions & Physical Requirements- Work is performed throughout a senior living community, including offices, resident apartments, clinical areas, common areas, and external healthcare settings.
- Regularly interacts with residents who may have physical, cognitive, behavioral, or communicable health conditions.
- May require occasional evening, weekend, holiday, or on-call availability based on resident needs and community operations.
- Local travel may be required to accompany residents, coordinate care, attend meetings, or support transitions between care settings.
- Requires the ability to remain mobile throughout the workday and to sit, stand, walk, bend, reach, and use standard office and clinical equipment.
- Requires the ability to communicate effectively in person and electronically and to review detailed clinical information.
- May occasionally require assisting with resident mobility or emergency response consistent with training and organizational policy.
- May involve exposure to blood, bodily fluids, infectious conditions, medications, chemicals, and other healthcare-related hazards.
- Requires the use of appropriate personal protective equipment and adherence to infection-prevention procedures.
Target pay range: 118-144K depending on experience
Location: Terraces at Los Altos
