RN Case Manager – Post-Acute & Transitional Care

Community Health Centers of America•Fairoaks, CA

20h•$60 - $75•Hybrid

About The Position

Community Health Centers of America (CHCA) is seeking a highly motivated and compassionate Registered Nurse (RN) Case Manager to support its High Presence Model of Care within Skilled Nursing Facilities (SNFs). The RN Case Manager serves as a clinical care coordinator and population health resource focused on reducing avoidable hospital readmissions, improving transitions of care, supporting preventive services, and facilitating interdisciplinary coordination for medically complex post-acute and long-term care patients. This will be a full-time in-person position working at facilities in the greater Sacramento area and at our administrative office in Fair Oaks. This role works collaboratively with CHCA physicians, nurse practitioners, physician assistants, social workers, facility nursing staff, specialists, and ancillary service providers to improve patient outcomes and continuity of care. This position primarily functions within Skilled Nursing Facilities and outpatient clinical settings, serving vulnerable and underserved populations. The RN Case Manager position is designed to support care coordination, quality improvement, patient education, transitional care, and clinical resource management functions in compliance with applicable California nursing laws and regulations. The RN Case Manager does not independently diagnose, prescribe, or direct medical treatment plans outside the scope of RN licensure and physician/provider oversight.

Requirements

Active and unrestricted California Registered Nurse (RN) license required.
Minimum of 2 years of nursing experience preferred.
Experience in skilled nursing, geriatrics, case management, transitional care, home health, hospice, or population health strongly preferred.
Knowledge of Medicare, care transitions, chronic disease management, and SNF operations preferred.
Strong communication, organizational, and interdisciplinary collaboration skills.
Experience with EMR systems preferred.
Valid California driver’s license and reliable transportation may be required for facility travel.

Nice To Haves

Knowledge of Transitional Care Management (TCM) workflows.
Experience working with medically complex geriatric populations.
Familiarity with quality improvement initiatives and readmission reduction strategies.
Ability to build collaborative relationships with SNF staff, providers, patients, and families.
Bilingual skills are a plus.

Responsibilities

Conduct post-discharge outreach and transitional care coordination for eligible patients following SNF transitions.
Assist providers in identifying and addressing causes of avoidable hospital readmissions through chart review, interdisciplinary collaboration, and care coordination activities.
Participate in clinical assessment for readmission root-cause analyses and quality improvement initiatives.
Monitor high-risk patients for gaps in follow-up care, medication reconciliation needs, specialty referrals, or barriers to treatment adherence.
Coordinate timely follow-up appointments with CHCA clinics and providers after discharge.
Support implementation of evidence-based care transition workflows.
Assist in identifying patients eligible for Annual Wellness Visits and preventive screenings.
Coordinate scheduling, documentation preparation, screening tools, and patient education related to preventive services.
Support providers with health risk assessments, care gap tracking, and patient outreach activities.
Educate patients and families regarding preventive health services and chronic disease management.
Facilitate referrals, scheduling, follow-up, and communication related to CHCA specialty and ancillary services, including but not limited to: Psychiatry / Behavioral Health, Dentistry, Podiatry, Social Work, Transitional Care Services, and Other specialty programs offered through CHCA.
Collaborate with SNF staff and CHCA providers to identify patients who may benefit from specialty services.
Track referral completion, barriers to care, and follow-up outcomes.
Maintain communication between specialty providers, facility staff, patients, and families.
Participate in interdisciplinary care coordination meetings and quality assurance activities.
Collaborate with facility nursing teams to support continuity of care and patient-centered treatment planning.
Assist with coordination of laboratory, imaging, medication, and follow-up recommendations as delegated by licensed providers.
Promote patient and family understanding of care plans and available services.
Support patient navigation and resource linkage for medically and socially complex patients.
Maintain accurate and timely documentation within the electronic medical record (EMR).
Support quality metrics, population health initiatives, and value-based care objectives.
Assist with tracking and reporting quality indicators related to readmissions, preventive care, and care coordination activities.
Adhere to all applicable HIPAA, CMS, California Board of Registered Nursing, and organizational policies and procedures.
Perform duties consistent with RN scope of practice under California law.