RN Case Manager (North)

Manage a caseload of home health patients by conducting Start of Care admissions, comprehensive assessments, and ongoing evaluations to identify needs. Develop, implement, and update individualized plans of care in collaboration with physicians and the interdisciplinary team. Coordinate nursing, home health aide, therapy, and other support services to ensure high-quality, seamless patient care while monitoring progress and adjusting plans as needed. Educate patients and caregivers on diagnoses, medications, and self-management strategies. Complete timely clinical documentation in accordance with agency, state, and Medicare guidelines, and participate in discharge planning to ensure smooth transitions.