The Nurse Case Manager (R.N.) plays a critical role in ensuring smooth transitions for patients entering and leaving a skilled nursing and rehabilitation facility. This nurse serves as a liaison between patients, families, healthcare providers, and facility staff to coordinate care plans, assess patient needs, and ensure compliance with regulatory and clinical standards. Job responsibilities include:

· Conduct comprehensive nursing assessments upon patient admission.

· Review medical records and physician orders to determine appropriate level of care.

· Collaborate with interdisciplinary teams to develop individualized care plans.

· Educate patients and families about facility services, policies, and expectations.

· Coordination of admissions and discharges that meet organizational objectives and resident treatment and care goals.

· Establishes strong collaborative relations with internal and external shareholders to promote positive relations with the residents, family members, and internal/external care partners.

· Attends required Safety and Prevention educational sessions and acknowledges safe practices.

Attends and participates in organizational initiatives and meetings including Quality Assurance Program Initiative (QAPI), Utilization Review, Marketing, daily Admissions Meetings, and others as requested. 

• Active and unrestricted Massachusetts Registered Nurse (RN) license. 
• Graduate of an accredited nursing program (associate or bachelor’s degree in nursing). 
• Minimum of 3-5 years of clinical nursing experience, preferably in skilled nursing, rehabilitation, or acute care setting.
•  Strong clinical assessment and critical thinking skills. 
• Knowledge of Medicare/Medicaid regulations and insurance authorization processes.
• Experience with admissions and discharge planning. 
• Proficient in electronic medical records (EMR) and documentation standards. 
• Proficient computer use of Microsoft Office and/or OneDrive. 
• Strong interpersonal, verbal, and written communication skills. 
• Excellent organizational skills. 
• Certifications: CPR/BLS certification required.

Working Conditions:

• Fast-paced healthcare environment.
• May require occasional evenings or weekend coverage depending on patient admission needs. 

PM17

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