About Job
- Support Client Wellness and Implement Comprehensive Care Planning – Evaluate clients and caregivers for well-being, environmental concerns, and social determinants of health. Through thorough assessments you will evaluate client strengths, needs, and preferences to develop and implement personalized care plans that promote effective education, self-management, wellness and timely care delivery. Translate client needs into actionable goals and connect them with resources and tools to support their agreed-upon ideals. Implement social and clinical pathways. Assist in programming and collaborating with population health strategies to improve health outcomes for aging and at-risk communities.
- Coordinate Care and Support Networks – Collaborate with healthcare providers, community-based organizations, and the client’s care network to ensure a coordinated, high-quality care experience. Facilitate appropriate referrals and connections to promote effective education, self-management, enhance cost-effectiveness, quality outcomes and timely service delivery. Manage and monitor the ongoing provision and need for care delivery to promote optimal health and financial outcomes. Support at-risk clients with aging care and service needs, fostering engagement and coordination across multiple health and community-based entities. Assist in implementing remote patient monitoring equipment. Assist in implementing remote patient monitoring equipment.
- Client Advocacy and Professional Support – Act as an advocate for clients by ensuring their healthcare needs are met and minimizing fragmentation in the healthcare delivery system. Uphold professionalism by maintaining legal and ethical standards, privacy requirements, and professional boundaries.
- Other Duties as Assigned – The duties and responsibilities listed above are representative in the nature of work and level of work assigned and are not necessarily all inclusive.
- Current Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in the state of Minnesota.
- CPR certification required.
- Participating in weekend call coverage.
- Strong clinical assessment and care planning skills.
- Experience in care management, population health, or community health nursing preferred.
- Experience working with aging populations, understanding geriatric care, and familiarity with health and social resources are highly valued.
- Proficiency in basic medical terminology and the ability to interpret clinical and social information.
- Valid driver’s license and access to insured personal vehicle.
- Ability to pass state mandated background check.
- Physical capability to perform job duties.
- Ability to read, write, and speak English to communicate effectively with staff, patients, families, and external partners.
- Employment Type: Hourly, non-exempt (eligible for overtime)
- Department: Nursing
- Leadership Received: Director of Care Management & Integration and Lead Care Manager
- Division: Population Health
- Travel Requirements: Yes
- This role does not include supervisory responsibilities.
Professional Field


Patient Focus
Diagnoses
Avoidant Personality Disorder
Issues
Aging
Age Groups
Elderly (65+)
Therapeutic Approach
Methodologies
ECT
Practice Specifics
Populations
Victims of Crime/Abuse (VOC/VOA)
Settings
Milieu
Research Facilities/Labs/Clinical Trials
Residential Treatment Facilities (RTC)
Schools
Telehealth/Telemedicine
Home Health/In-home
Forensic
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