About The Role

Perform comprehensive patient assessments to identify clinical, psychosocial, and discharge planning needs.
Develop, implement, and evaluate individualized case management plans.
Coordinate patient care across multidisciplinary teams to ensure continuity of care.
Facilitate discharge planning, including post-acute care placement, home health services, rehabilitation, durable medical equipment (DME), and community resources.
Review patient progress, monitor length of stay, and support efficient utilization of healthcare resources.
Collaborate with physicians, nursing staff, social workers, and insurance providers to ensure appropriate levels of care.
Maintain accurate and timely documentation in the electronic medical record (EMR).
Ensure compliance with hospital policies, CMS guidelines, regulatory standards, and payer requirements.
Advocate for patients and families while promoting safe, high-quality outcomes.

Experience Required: 2-year acute medical Care Manager experience performing Care Coordination
Experience: Travel experience required

Charting: EPIC required

Experience with Assessing patients, Care Coordination, and Discharge Planning.
Ability to organize and participate in family meetings.
Participate in the development of the treatment plan.
Experience with HMOs, IPAs, etc.
Knowledge of adoption/foster care, drug/alcohol abuse treatment options, patients experiencing homelessness, patients with mental health history or in crisis, advance directive, POLST, protective services process, etc.
Competent with arranging DME, SNF and ambulance transport. Must be able to perform this task independently.

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Registered Nurse (Case Manager) - Travel/Contract - Mission Viejo, CA