At Mahaska Health the Case Management Registered Nurse provides patient-centered support across the continuum of care. This role coordinates social assessments, care planning, discharge arrangements, and resource navigation for patients with diverse medical, behavioral health, and social needs. The position works closely with physicians, nursing staff, ancillary departments, and community partners to ensure safe, timely, and appropriate transitions of care. Collaborates with Medical Providers, using Nationally accepted admission criteria, to ensure that the care provided is necessary and at the most appropriate level of care for patients receiving inpatient care at Mahaska Health.
Full-time (Weekend Package 7am – 7pm) 35% pay incentive for weekend package.
Essential job responsibilities include but are not limited to,
- Evaluate Socio-Economic patient needs, barriers to recovery or discharge, and risk factors impacting care transitions.
- Coordinate and implement safe, timely discharge plans, including arranging post‑acute services such as home health, skilled nursing facility placement, DME, transportation, and community‑based supports.
- Facilitate family meetings and interdisciplinary care conferences to support shared decision‑making and patient-centered planning.
- Ensure compliance with Medicare Conditions of Participation, swing‑bed regulations, and Critical Access Hospital requirements in all case management and discharge planning activities.
- Collaborate with interdisciplinary team to coordinate crisis intervention referrals for mental health, substance use treatment, financial assistance, protective services, and other community resources.
- Provide patient, family, and staff education upon request or assignment, ensuring documentation of all educational encounters.
- Participate in departmental and organizational performance improvement initiatives, completing assigned tasks in accordance with regulatory, hospital, and departmental standards.
- Be flexible and able to multi-task; can work within an ambiguous, fast-moving environment, while also driving toward clarity and solutions; demonstrated resourcefulness in setting priorities.
Job Requirements include but are not limited to,
- A graduate from an accredited school of nursing and currently licensed as a Registered Nurse in the state of Iowa (or) a graduate from an accredited school of nursing and currently licensed as a Registered Nurse able to work in the state of Iowa.
- Bachelor’s degree in Social Work, Nursing, Human Services, Psychology, or related field required; Master’s degree in Social Work (MSW) preferred.
- Prior experience in medical social work, case management, discharge planning, or care coordination preferred.
- Experience in a hospital, Critical Access Hospital, rural health setting, long‑term care, or community-based services are strongly beneficial.
- Familiarity with Medicare/Medicaid regulations, swing-bed programs, and post‑acute care systems preferred.
- Experience working with diverse populations, including older adults, individuals with chronic illness, behavioral health needs, or limited resources.
- Strong understanding of assessing for social needs, crisis intervention, and care‑planning principles.
- Knowledge of community resources, social service systems, protective services, mental health and substance use treatment options, and financial assistance programs.
- Strong organizational and time‑management skills, with the ability to prioritize in a fast‑paced rural environment where resources may be limited.
- Excellent verbal and written communication skills, including documentation that meets regulatory and organizational standards.
