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.