Case Manager

Summary

The Nurse Case Manager meets and works with individuals to gather information; assess each individual's needs; assess the plan and cost of care; and identify and implement services to meet an individual's needs. They are responsible for providing nursing services, training, and support to address the medical or psychiatric needs of individuals with developmental disabilities, acquired brain injuries, substance abuse issues and/or emotional or behavioral challenges. 

Essential nursing job functions
To perform this job successfully, an individual must be able to satisfactorily perform each essential function listed below:  

• Conducts the medical assessment of each individual referred to the program and collaborates with an Intake staff member to determine appropriate placement in the community
• Participates in the development and implementation of service plans and supervises, in conjunction with the physicians, the medical components of the plan  
•  Reviews documents and revises all nursing/nursing related care plans on a regular basis
• Ensures medical records and reports are current and complete in accordance with regulatory and corporate standards, including medication administration records and physician’s orders
• Maintains contact with primary care physicians and specialists, and, when directed, attends doctor visits with mentor and/or individual receiving services.
• Promotes health and wellness for individuals and ensures nursing actions and steps are put in place for prevention
• Administers medications according to established guidelines  
• Provides documentation for all medications given and reviews medication administration records for compliance
• Oversees the management of high-risk medical conditions and private duty nursing services
• Develops training flow charts specific to each individual receiving services, provides and documents medical skills training to clients, mentors, respite providers, staff, and where appropriate, the biological family
• Presents medical skills components at Pre-service Orientation
• Participates as an Individual Health Plan (IHP) or Plan of Care (POC) team member,
• Evaluates the medical needs of each individual for initial IHP/POC,
• Ensures IHP/POC goals and objectives are medically indicated, and
• Generates ongoing health care protocols for the specific medical conditions outlined in the IHP/POC
• Provides consultation and technical assistance to staff and mentors regarding home care issues along with operation of durable medical equipment.
• May be required to coordinate, organize and/or assist with household activities such as light housekeeping and meal preparation; transport individuals receiving services to planned and/or necessary activities and appointments  
• Participates in on call system as needed
• May actively participate in IDT meetings, Human Rights Committee, Health and Safety Committee and Administration meetings 
  Performs other related duties and activities as required 

Essential Case Management Job Functions
Participant Care & Coordination

•    Facilitate all components of case management, including intake, assessment, planning, advocacy, and ongoing monitoring.
•    Conduct home, residential, and community visits to evaluate participant progress and needs.
•    Coordinate care across interdisciplinary teams (nursing, therapy, behavioral health, residential, and medical providers).
•    Prevent duplication of services by maintaining close communication among all providers.
•    Identify, recommend, and connect participants to community resources that enhance independence and quality of life
•    Plan of Care Development & Oversight
•    Develop individualized care plans with measurable goals and target outcomes.
•    Collaborate with the participant, family, and team members to ensure plans remain current and effective.
•    Track service delivery to confirm alignment with the plan of care and participant objectives.
•    Assist individuals in obtaining benefits (Medicaid, Medicare, Social Security, private insurance) and maintain current knowledge of eligibility processes
Follow-Up & Communication Management
•    Maintain consistent follow-up on all participant needs, ensuring timely completion of next steps and documentation.
•    Communicate proactively with internal and external partners regarding updates, barriers, and progress.
•    Serve as the lead contact for participant, guardian, and external case manager communication.
•    Track open items and follow-through using established organizational systems to ensure accountability.
•    Escalate unresolved issues promptly to leadership and support timely resolution.
 
Documentation & Reporting
•    Maintain accurate, detailed, and up-to-date electronic case records.
•    Document all communication, follow-up, and outcomes in alignment with organizational standards.
•    Monitor timelines for plan updates, re-assessments, and required reviews.
•    Provide progress summaries and updates during internal rounds, team meetings, and case reviews.

Professional Standards & Collaboration
•    Demonstrate professionalism, empathy, and respect in all interactions with participants, families, and staff.
•    Collaborate effectively with program leaders, therapists, nurses, and residential teams.
•    Identify and communicate opportunities for service improvement or process streamlining.
•    Participate in audits, trainings, and departmental initiatives to promote continuous improvement.

Minimum Knowledge and Skills required by the Job 
The requirements listed below are representative of the knowledge, skill, and/or abilities required to perform the job:  
  
Education and Experience:  
•    Graduate of an accredited RN program 
•    One year experience working with medically complex individuals. 
Certificates, Licenses, and Registrations: 
•    Current state RN License 
•    Current driver's license, car registration and auto insurance if providing transportation to individuals receiving services.  
•    Current CPR/First Aid certification.
Knowledge & Skills:
•    Strong working knowledge of case management practices, care coordination, and interdisciplinary communication.
•    Exceptional interpersonal and relationship-building skills; able to establish rapport quickly and maintain professional communication across all levels.
•    Demonstrated ability to manage multiple priorities and deadlines in a dynamic environment.
•    Skilled in problem-solving and crisis intervention with sound judgment and minimal supervision.
•    Competent in analyzing data, monitoring progress metrics, and identifying trends to support follow-up and performance management.
•    Proficiency with Microsoft Office Suite (especially Excel, Word, and Outlook) and electronic health record systems.
•    Strong written and verbal communication skills, including report writing and documentation.
•    Ability to interpret and apply policies, procedures, and applicable regulations.
•    Demonstrated commitment to teamwork, accountability, and continuous improvement.
Blood Borne Pathogen Category: 
•    Job requires performance of duties that involve potential for exposure to blood, body fluids, or tissues. Tasks that do involve exposure are an expectation of employment.

Physical Requirements: 
Heavy work.  Exerting up to 100 pounds of force occasionally, and/or up to 50 pounds of force frequently, and/or up to 20 pounds of force constantly to move objects. 

Other Requirements: 
Travel as needed