Registered Nurse (R.N.) Geriatric Case Manager - Home Care (Full-Time, Days)

The role is responsible for the delivery of comprehensive nursing care to a set of assigned patients thru the RRH Geriatric Service Verification program. This involves the pre-surgical assessment of eligible patients in the GSV program. The RN will work with the patient, family, Geriatric APP team to recognize post discharge needs and the development, implementation and evaluation of an appropriate Plan of Care. The incumbent will make changes in response to evaluation & assessment of patient needs. The role identifies appropriate interdisciplinary services needed, coordinates those services and supervises the delivery of care.

• Master’s in Nursing: Healthcare Leadership or Geriatric NP
• Geriatric nurse case managers will work in various settings, including hospitals and patient homes. They need strong communication, organizational, and problem-solving skills to effectively support their clients
• Consistently demonstrates high standards of integrity by supporting the Rochester Regional Health Companies’ mission and values and adhering to the Corporate Code of Conduct

• →Conducts Comprehensive Assessments of older adults’ physical, emotional, cognitive, and social needs, including pre-surgical in-home evaluations and post-discharge follow-up, with a focus on identifying and addressing Social Determinants of Health.
• →Develops and Implements Interdisciplinary Care Plans in collaboration with patients, caregivers, and healthcare teams to support recovery and independence in the least restrictive setting.
• →Coordinates and Monitors Care by navigating health systems, ensuring timely services, tracking patient progress, and adjusting care plans as needed to meet individual goals.
• →Responds to Health Crises and Advocates for Patients, addressing emergencies like hospitalizations and ensuring high-quality, patient-centered care aligned with individual preferences.
• →Provides Leadership and Quality Oversight, including supervising care teams, mentoring new staff, documenting thoroughly, participating in quality improvement, and supporting program growth.

• Associates Degree in Nursing
• A minimum of 2 years of nursing experience in home care, geriatric care or case management
• Registered Nurse license in New York State
• Valid NYS Driver’s License

The posted pay range is a good faith representation of potential base pay for this position. It may be modified in the future and eligible for additional pay components. Individual annual salaries/hourly rates could vary based on position details and FTE. Pay is determined by considering factors including, but not limited to, experience, relevant qualifications, specialty, internal equity, locations, and contracts.