RN Case Manager - TSC

Registered Nurse (RN) Case Manager – Palliative Care

The RN Case Manager supports the delivery of comprehensive outpatient palliative care by providing telephonic nursing support, clinical care coordination, patient triage, and ongoing case management for patients with serious and chronic illness. The RN works closely with palliative care providers, patients, caregivers, primary care providers, specialists, and community partners to address clinical needs, close gaps in care, and ensure timely access to appropriate services.

Key responsibilities include:

• Providing telephonic assessment, triage, education, and support to palliative care patients and caregivers.
• Coordinating clinical needs including medication refills, DME, home health, home infusion, laboratory services, referrals, appointments, and other patient-care services.
• Monitoring changes in patient condition and escalating urgent or emergent concerns to the appropriate provider.
• Supporting development, implementation, and ongoing review of individualized plans of care in collaboration with the interdisciplinary team.
• Providing proactive clinical follow-up for patients enrolled in Principal Care Management (PCM), including care coordination, disease-specific support, medication management, patient/caregiver education, and communication with treating providers.
• Accurately documenting and tracking time spent performing qualifying PCM activities to support clinical continuity, regulatory compliance, and appropriate billing.
• Identifying clinical and non-clinical barriers to care and coordinating resources necessary to address patient and caregiver needs.
• Supporting palliative care Nurse Practitioners by managing follow-up needs and care-coordination activities, allowing providers to focus on direct patient care.
• Participating in interdisciplinary team meetings, quality-improvement activities, and other program initiatives.

Minimum Qualifications: Current Florida RN license; graduate of an accredited nursing program; current CPR certification; strong clinical assessment, care coordination, communication, documentation, and organizational skills. Experience with palliative care, hospice, geriatrics, chronic disease management, or care management is preferred.

• Current, unrestricted Registered Nurse (RN) license in the State of Florida.
• Graduate of an accredited school of nursing; Associate or Bachelor’s degree in Nursing required.
• Minimum of 2 years of clinical nursing experience; experience in palliative care, hospice, geriatrics, chronic disease management, case management, home health, or care coordination strongly preferred.
• Experience providing telephonic nursing assessment, patient triage, care coordination, and patient/caregiver education.
• Demonstrated ability to recognize changes in patient condition and appropriately escalate routine, urgent, and emergent clinical concerns.
• Knowledge of palliative care principles, chronic illness management, symptom management, and goals-of-care support.
• Experience coordinating services such as DME, home health, medications/refills, laboratory services, referrals, specialist appointments, and other community-based healthcare resources.
• Knowledge of or experience with Principal Care Management (PCM) or other care-management programs, including documentation of care-management activities and accurate tracking of qualifying clinical time, preferred.
• Strong clinical documentation skills and ability to maintain accurate, timely, and compliant electronic health records.
• Excellent verbal and written communication, critical-thinking, problem-solving, organizational, and time-management skills.
• Ability to independently prioritize a high-volume caseload while collaborating effectively with Nurse Practitioners, physicians, social workers, caregivers, and other members of the interdisciplinary care team.
• Proficiency with electronic health records, Microsoft Office, and other healthcare technology.
• Current CPR certification in accordance with organizational requirements.
• Valid driver’s license, reliable transportation, and automobile insurance meeting organizational and State of Florida requirements.
• Hospice and palliative care certification or other relevant specialty certification is preferred.