CARE NURSE JOB DESCRIPTION

A Care Nurse holds a working definition most nurses understand immediately: the person accountable for what happens to a patient between settings. This role spans acute inpatient units, skilled nursing facilities, and community-based transitions, coordinating care across interdisciplinary teams while applying HIPAA-compliant documentation and utilization review standards. Joint Commission requirements and Medicare/Medicaid coverage determinations shape daily clinical decisions. The role demands both bedside clinical judgment and the systems-level thinking needed to reduce avoidable hospitalizations.

As the Care Nurse, you are accountable for comprehensive patient assessment, care plan development, and transition coordination across the care continuum, directly reducing hospital readmissions for medically complex and high-risk populations. You will operate within a multidisciplinary team that includes physicians, social workers, discharge planners, and community health organizations, with scope extending from inpatient facilities into post-discharge home and community settings.

Career Impact: Clinical experience across inpatient, SNF, and community case management settings positions a Care Nurse to pursue CCM or CCTM certification and advance into care coordination leadership within managed care or health system environments.

Business Impact: Effective transitional care management directly lowers avoidable emergency department utilization and 30-day readmission rates for high-risk populations, outcomes that determine both patient welfare and value-based contract performance.

Growth Opportunity: Exposure to utilization review, social determinants of health frameworks, and interdisciplinary care conferences builds the clinical and operational fluency required for senior care management or population health program roles.

• Conduct comprehensive assessments of patients' medical, behavioral, and social needs to identify barriers, strengths, and appropriate care interventions.
• Develop and implement individualized care plans in collaboration with physicians, social workers, and the broader interdisciplinary team.
• Coordinate post-discharge transitions, including 48-hour follow-up contacts and home visits for high-risk residents within seven days of discharge.
• Facilitate communication between primary care providers, hospitalists, and skilled nursing facility teams to align on discharge planning and continuity of care.
• Perform utilization reviews evaluating treatment plans and identifying alternative care options appropriate to each member's acuity and social context.
• Monitor patient response to medications and nursing interventions, documenting outcomes and adverse effects in accordance with unit policies and regulatory standards.
• Advocate for patients and families during care conferences, warm handoffs, and transitions between care settings to ensure continuous engagement.
• Partner with community organizations and referral sources to address social determinants of health and connect patients with appropriate post-acute resources.

• Bachelor's degree in Nursing or equivalent work experience.
• 3 or more years of clinical nursing experience, with exposure to at least two care settings such as hospital, SNF, home health, or rehabilitation.
• Current licensure as a Registered Nurse in the state of employment.
• Working knowledge of Medicare, Medicaid, and insurance authorization processes relevant to acute and post-acute care.
• Demonstrated ability to perform clinical assessments and apply the nursing process across medically complex patient populations.
• Proficiency in electronic medical records documentation and reporting functions.
• Knowledge of HIPAA regulations and ability to handle confidential health information in compliance with federal and state law.
• Strong oral and written communication skills for coordination across multidisciplinary teams and patient/family education.

• Case Management certification (CCM or CCTM) or active progress toward certification within an accredited program.
• Prior experience conducting utilization review or applying Clinical Institute Withdrawal Assessment (CIWA) protocols in acute care settings.
• Familiarity with value-based care models and population health metrics used in managed care or accountable care organizations.
• Experience in facilitating interdisciplinary care conferences and conducting post-discharge home visits for high-risk or geriatric populations.

• 30-day readmission rate for managed patient cohort, measuring effectiveness of transitional care planning and post-discharge follow-up.
• Post-discharge contact completion rate within 48 hours and 7 days, tracking adherence to high-risk transition protocols.
• Utilization review turnaround time, reflecting timely identification of appropriate level-of-care alternatives.
• Care plan completion rate within required admission timeframes, per unit policy and Joint Commission standards.
• Emergency department visit frequency for high-utilizer members, indicating success in redirecting members to appropriate care settings.
• Typical tools: Electronic medical records (commonly Epic or Cerner); care coordination platforms (commonly PointClickCare or similar SNF/ACO tools).

• Base Salary Range: $72,000 to $95,000 annually, depending on setting and experience
• Bonus: Annual performance bonus of 3% to 6% where applicable
• Equity: Not typically offered in healthcare settings
• Health Benefits: Medical, dental, and vision coverage; employer contribution standard
• PTO: 15 to 22 days annually, plus paid holidays
• Common Perks: CEU reimbursement, licensure renewal support, certification exam assistance

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Background checks, including applicable drug screening, are a standard condition of employment for patient-facing roles. All qualified applicants will be considered without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected under federal, state, or local law. Applicants requiring a reasonable accommodation during the hiring process should notify the recruiting team. Candidates must be authorized to work in the United States.

The Care Nurse owns the delivery of perioperative and post-anesthesia care within a Medical Intermediate Care Unit, delegating and supervising RNs, LPNs, NAs, and support staff in the absence of the nurse manager. Working in alignment with Joint Commission, DPH, and federal and state standards, the Care Nurse shapes patient outcomes by developing care plans with multidisciplinary teams and integrating performance improvement activities across the unit.

Key Responsibilities

• Lead patient care delivery as team leader in the absence of the nurse manager, assigning and supervising RNs, LPNs, NAs, and support staff.
• Ensure nursing care meets established standards with ongoing documentation under the direction of the Nurse Manager/Charge Nurse.
• Initiate physical, psychosocial, and spiritual assessments of patient needs according to admission procedures and unit policy.
• Develop a Plan of Care with the patient, significant others, and the multidisciplinary health care team.
• Implement and document nursing interventions per care plan, nursing theory, and Joint Commission, DPH, and federal and state requirements.
• Transcribe physician orders accurately and administer, document, and monitor prescribed medications and adverse effects.
• Provide ongoing assessment and evaluation of patient status to determine intervention effectiveness and treatment response.
• Document nursing care processes and outcomes in accordance with unit policies and procedures.
• Educate patients and significant others to improve health outcomes, health literacy, and return to function.
• Perform charge duties as delegated and contribute to performance improvement and risk management activities.

Required Qualifications

• Licensed Registered Nurse with demonstrated knowledge of critical care and perioperative nursing.
• Experience assessing patients per the Clinical Institute Withdrawal Assessment (CIWA) scale and medicating appropriately.
• Knowledge of scientific theories and principles of nursing in medical/surgical or critical care settings.
• Familiarity with supervision principles and the capacity to coordinate the efforts of others.
• Competent in administering medications including antibiotics, analgesics, TPN, and ventilator management agents.
• Ability to recognize symptoms of mental illness and emotional disorders.
• Ability to remain calm, make decisions, and act quickly in stressful situations or emergencies.
• Proven ability to prioritize and re-prioritize effectively in emergency and critical care situations.
• Can collaborate and communicate through oral and written reporting with interdisciplinary team members.
• Strong ability to establish rapport with persons from varied ethnic, cultural, and socioeconomic backgrounds.

Embedded within a skilled nursing facility, the Care Nurse delivers transitional services to new residents at admission and follows patients post-discharge into the community, working closely with admissions, interdisciplinary, and home health teams to reduce hospital readmissions. The Care Nurse builds and maintains referral source relationships that support census growth and keep the facility competitive in the long-term care market.

Core Functions

• Represent the facility professionally when visiting hospitalized patients and newly approved inquiries before admission.
• Determine needs of referral sources and identify how the facility can best meet those needs, forwarding new business opportunities to the marketing team.
• Collaborate with the admissions team to understand admission and discharge trends, bed availability, and referral needs.
• Provide market feedback to the marketing, admissions, and leadership teams to keep the facility competitive.
• Attend initial care conferences for new admissions within 72 hours.
• Educate residents and family members regarding disease process, short-term stay expectations, and discharge planning.
• Coordinate with the interdisciplinary team and home health providers for 48-hour discharge planning meetings.
• Contact the primary care physician before discharge to schedule the first post-discharge medical appointment.
• Conduct at least one post-discharge home visit for high-risk residents within 7 days of discharge.
• Complete weekly post-discharge phone calls for 30 days for short-stay residents.

Qualifications & Experience

• Graduate of an accredited school of nursing.
• 3 to 5 years of experience in long-term care and/or geriatrics.
• Working knowledge of Medicare, Medicaid, and other insurance types.
• Knowledge of facility programs with the ability to communicate them to referral sources.
• Proficiency in Word and Excel, with prior knowledge of a contact database application.
• Good verbal, written, and presentation skills.
• Strong organizational skills with the ability to work independently and manage schedule flexibly.
• Self-motivated with the ability to work as part of a team.
• Ability to travel throughout the assigned region.

Reporting to the medical director, the Care Nurse leads face-to-face and telephonic case management services for vulnerable and at-risk members across hospital, SNF, and community settings, performing utilization reviews and comprehensive assessments to address social determinants of health. Partnering with inpatient facility teams, primary care providers, and community organizations, the Care Nurse advances member transitions to home and reduces avoidable emergency room visits and hospitalizations.

Primary Duties

• Provide face-to-face and telephonic case management services to vulnerable and at-risk members.
• Visit inpatient members and high utilizers of emergency room or observation stays to coordinate care and identify alternative service options.
• Perform utilization reviews evaluating treatment plans and offering care alternatives specific to members facing social determinants of health.
• Consult with the medical director for difficult cases requiring collegial discussions with facility physicians and family meetings.
• Facilitate communication between primary care providers, hospitalists, and SNF teams regarding care, treatment, and discharge planning.
• Perform comprehensive assessments to evaluate medical, social, and behavioral needs while identifying member strengths, barriers, and resources.
• Intervene at the time of condition exacerbation to help members utilize healthcare services appropriately and avoid unnecessary hospitalizations.
• Collaborate with inpatient and multidisciplinary teams to facilitate post-discharge planning and transition to home.
• Establish and maintain working relationships with inpatient facilities and community organizations regarding public health topics.
• Advocate for members and families through warm handoffs and proactive communication.

Skills & Qualifications

• Bachelor's degree, with Case Management or Care Coordination certification (CCM or CCTM) preferred.
• Licensed Registered Nurse with 3 or more years of complex case management experience across at least two care settings.
• Experience working with high-risk and medically complex patients with multiple comorbidities.
• Knowledge of city population, geography, and community resources.
• Experience in analyzing and leveraging reporting capabilities of Electronic Medical Records.
• Working knowledge of Microsoft Office Suite including Word, Outlook, PowerPoint, and Excel.
• Ability to handle confidential health care information in compliance with HIPAA guidelines.
• Excellent communication, leadership, and organizational skills with strong attention to detail.
• Ability to adapt effectively in a complex, results-oriented environment and manage competing priorities.
• Willingness to travel up to 75% of the time to local hospitals, SNFs, and community organizations.