Registered Nurse Case Manager - Senior Care

Allina Health Systems•Minneapolis, MN

50d•$42 - $58

About The Position

Allina Health is a not-for-profit health system that cares for individuals, families and communities throughout Minnesota and western Wisconsin. If you value putting patients first, consider a career at Allina Health. Our mission is to provide exceptional care as we prevent illness, restore health and provide comfort to all who entrust us with their care. This includes you and your loved ones. We are committed to providing whole person care, investing in your well-being, and enriching your career. Key Position Details: 1.0 FTE (80 hours per two-week pay period) 8-hour day shifts No weekends This position will be within the Continuing Care Service line, in our home-based primary care program. We are looking with someone with either in-depth community experience, geriatrics, or care management Care management certified or will need to commit to becoming certified within a year of hire Required urgent visits and home visits Located in or willing to travel to the central and south metro Nursing is the assessment and treatment of human response to actual or potential health problems. This includes establishing an intentional therapeutic relationship between a registered nurse and a patient and family. As a leader and the integrator of care, the professional nurse has the responsibility, authority, and accountability for planning, coordinating and evaluating the patient's care needs. Provides proactive, comprehensive care coordination for high-risk geriatric patients to improve outcomes, enhance quality of life, and reduce unnecessary healthcare use. Independently manages a complex patient panel, leading interdisciplinary care planning to support patient function and access to services. Advocates for patients facing complex health issues through a person-centered, team-based approach. Serves as a clinical resource, using nursing judgment and communication skills to assess patient needs, guide care decisions, and support diagnosis-based outcomes. Assists the care team in triaging and addressing acute and chronic concerns for complex patients.

Requirements

Associate or Vocational degree in nursing and 5+ years of community experience OR
Bachelor's degree in Nursing
3+ years care management experience, home care, or clinic experience including a deep understanding of geriatric syndromes, chronic disease trajectories, and end-of-life care
Licensed Registered Nurse - MN Board of Nursing required if working in state of MN upon hire / WI Department of Safety & Professional Services required if working in the state of WI upon hire
Must meet at least ONE of the requirements below: Current BLS certification from the American Heart Association Current BLS certification from the American Red Cross Allina in-house BLS training (within 3 months of hire)
Valid Driver's License required upon hire - MN and WI residents must obtain a valid driver's license in their state of residence within 60 days of employment

Nice To Haves

Nursing Case Management Certification (CMGT-BC) preferred

Responsibilities

Conducts holistic assessments through chart review and direct interaction, addressing clinical, emotional, psychosocial, social needs and barriers, and functional barriers.
Coordinates transitional care to reduce readmissions and support smooth discharges, including advance care planning and hospice transitions when appropriate.
Identifies risk factors and recommends interventions for complex conditions (e.g., heart failure, diabetes, COPD, dementia) and chronic needs.
Develops person-centered care plans aligned with clinical goals.
Uses data and risk tools to identify high utilizers and implement targeted interventions.
Monitors quality metrics and adjusts care plans accordingly.
Applies evidence-based practice and regulatory standards in care planning.
Identifies expected outcomes individualized to the patient.
Establishes, in the collaboration with the patient and caregiver, realistic and measurable patient expected outcomes based on nursing diagnoses, patients current and potential capabilities, goals, available resources and plan for continuity of care.
Implements interventions outlined in plan of care in a safe, timely, appropriate manner
Works with participant, caregivers and providers to resolve identified barriers and coordinate needed services.
Utilizes motivational interviewing skills to facilitate and engage participants towards behavioral changes through exploration and resolving ambivalence.
Facilitates communication between participant, caregivers and all members of the health care team, including referral facilitation to completion.
Documents interventions according to documentation guidelines.
Follows the participant over time, across continuum of care to measure effectiveness of the plan, modifying as necessary to accommodate changes for optimal health.
Collaborates with team to respond to acute and chronic needs of patient panel including hands on care (vital signs, wound assessments, modifying environment to fit care needs, administer vaccines, etc.).
Continuously evaluates patient and caregiver understanding, engagement, and outcomes related to the care plan using systematic assessment data.
Supervises and delegates to care management support staff tasks that contribute to the plan.
Participates in committees, workgroups, and departmental meetings to support quality improvement and problem-solving.
Collaborates with interdisciplinary teams to design and implement integrated, patient-centered care plans.
Other duties as assigned.

Benefits

Medical/Dental
PTO/Time Away
Retirement Savings Plans
Life Insurance
Short-term/Long-term Disability
Paid Caregiver Leave
Voluntary Benefits (vision, legal, critical illness)
Tuition Reimbursement or Continuing Medical Education as applicable
Student Loan Support Benefits to navigate the Federal Public Service Loan Forgiveness Program

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