Registered Nurse Case Manager-HCH Senior Care

Location Address:

2925 Chicago Ave Loading Dock Minneapolis, MN 55407-1321

Date Posted:

November 06, 2025

Department:

78007328 Senior Care Transitions Complex Care

Shift:

Shift Length:

8 hour shift

Hours Per Week:

40

Union Contract:

Non-Union-NCT

Weekend Rotation:

None

Job Summary:

Allina Health is a not-for-profit health system that cares for individuals, families and communities throughout Minnesota and western Wisconsin. If you value putting patients first, consider a career at Allina Health. Our mission is to provide exceptional care as we prevent illness, restore health and provide comfort to all who entrust us with their care. This includes you and your loved ones. We are committed to providing whole person care, investing in your well-being, and enriching your career.

Key Position Details:

• 1.0 FTE (80 hours per two-week pay period)
• 8-hour day shifts
• No weekends
• This position will be within the Continuing Care Service line, in our home-based primary care program. We are looking with someone with either in-depth community experience, geriatrics, or care management
• Care management certified or will need to commit to becoming certified within a year of hire
• Required urgent visits and home visits
• Located in or willing to travel to the central and south metro

Job Description:

Nursing is the assessment and treatment of human response to actual or potential health problems. This includes establishing an intentional therapeutic relationship between a registered nurse and a patient and family. As a leader and the integrator of care, the professional nurse has the responsibility, authority, and accountability for planning, coordinating and evaluating the patient’s care needs.

Provides proactive, comprehensive care coordination for high-risk geriatric patients to improve outcomes, enhance quality of life, and reduce unnecessary healthcare use. Independently manages a complex patient panel, leading interdisciplinary care planning to support patient function and access to services. Advocates for patients facing complex health issues through a person-centered, team-based approach.

Serves as a clinical resource, using nursing judgment and communication skills to assess patient needs, guide care decisions, and support diagnosis-based outcomes. Assists the care team in triaging and addressing acute and chronic concerns for complex patients.

Principle Responsibilities

• Assessment and Plan
  • Conducts holistic assessments through chart review and direct interaction, addressing clinical, emotional, psychosocial, social needs and barriers, and functional barriers.
  • Coordinates transitional care to reduce readmissions and support smooth discharges, including advance care planning and hospice transitions when appropriate.
  • Identifies risk factors and recommends interventions for complex conditions (e.g., heart failure, diabetes, COPD, dementia) and chronic needs.
  • Develops person-centered care plans aligned with clinical goals.
  • Uses data and risk tools to identify high utilizers and implement targeted interventions.
  • Monitors quality metrics and adjusts care plans accordingly.
  • Applies evidence-based practice and regulatory standards in care planning.
• Outcomes Identification
  • Identifies expected outcomes individualized to the patient.
  • Establishes, in the collaboration with the patient and caregiver, realistic and measurable patient expected outcomes based on nursing diagnoses, patients current and potential capabilities, goals, available resources and plan for continuity of care.
• Implementation
  • Implements interventions outlined in plan of care in a safe, timely, appropriate manner
  • Works with participant, caregivers and providers to resolve identified barriers and coordinate needed services.
  • Utilizes motivational interviewing skills to facilitate and engage participants towards behavioral changes through exploration and resolving ambivalence.
  • Facilitates communication between participant, caregivers and all members of the health care team, including referral facilitation to completion.
  • Documents interventions according to documentation guidelines.
  • Follows the participant over time, across continuum of care to measure effectiveness of the plan, modifying as necessary to accommodate changes for optimal health.
  • Collaborates with team to respond to acute and chronic needs of patient panel including hands on care (vital signs, wound assessments, modifying environment to fit care needs, administer vaccines, etc.).
• Evaluation and Professional Oversight
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