Nurse Case Manager

Reports to: Director of Nursing

JOB DESCRIPTION:

The Nurse Case Manager role requires a compassionate, clinically strong, and highly organized Registered Nurse (RN) within our Home Health Agency, responsible for both managing patient care across a defined caseload and personally delivering skilled nursing services in the home.

This role is critical to ensuring patients receive high-quality, compliant, and patient-centered care, while coordinating services across home health aides, skilled nursing, physicians, and internal team members. This position blends clinical excellence, care coordination, and compassion to ensure an optimum care experience for our patients.

RESPONSIBILITIES:

• Clinical Case Management:
• Perform comprehensive start-of-care, recertification, routine, and discharge assessments
• Develop, implement, and continuously update individualized plans of care in accordance with physician orders and HHA agency requirements
• Manage and oversee a caseload of home health patients, ensuring timely visits, continuity of care, and optimum care experience
• Monitor patient progress and proactively identify changes in condition, escalating as appropriate

• Skilled Nursing Care Delivery:
• Provide hands-on skilled nursing services in the home, including but not limited to:
• Wound care and dressing changes
• Medication management and administration
• Disease management and patient stabilization
• IV therapy (if applicable)
• Ensure all care provided aligns with physician orders and agency standards

• Care Coordination & Communication:
• Serve as the primary clinical point of contact for assigned patients
• Coordinate care with physicians, therapists, caregivers, aides, and family members
• Facilitate timely communication regarding patient status, changes, and care needs
• Participate in case conferences and interdisciplinary team meetings

• Supervision & Oversight:
• Provide clinical oversight and supervision of Home Health Aides (HHAs)
• Conduct supervisory visits and ensure care is delivered in accordance with the plan of care
• Support training, coaching, and development of field staff to ensure quality and consistency

• Documentation & Compliance:
• Complete accurate, timely, and compliant documentation in the EMR system
• Ensure adherence to Medicare/Medicaid guidelines, payer requirements, and state regulations
• Maintain compliance with OASIS documentation standards (if applicable)
• Follow all HIPAA, infection control, and agency policies

• Quality & Patient Experience:
• Promote a high standard of patient care and satisfaction
• Participate in quality assurance and performance improvement initiatives
• Identify opportunities to improve care delivery, efficiency, and outcomes

QUALIFICATIONS:

• Active Registered Nurse (RN) license in the State of Indiana (or applicable state)
• Minimum 1–2 years of nursing experience (home health or case management preferred)
• Strong clinical assessment and critical thinking skills
• Ability to independently manage time, priorities, and a patient caseload
• Excellent communication and interpersonal skills
• Valid driver’s license, reliable transportation, and current auto insurance
• Experience with OASIS documentation and EMR systems
• Knowledge of Medicare, Medicaid, and state home health regulations
• Current CPR certification