Home Health SOC/ROC/Recertification Nurse

Position Snapshot

• Position: Full-Time, Salaried RN Case Manager
• Salary: $90,000–$104,000/year
• Sign-On Bonus: $5,000
• Territory: Metro Area (West Metro preferred)
• Focus: SOCs, ROCs, Recertifications & Case Management
• Experience: 2 years in home care preferred
• Availability: Immediate
• Benefits: Health, Dental, Vision, Short- & Long-Term Disability, PTO & Sick Pay, Travel Stipend
• Reports To: Director of Nursing

Alliance Home Health Care & Nursing Services is seeking an experienced Home Health RN Case Manager for a full-time salaried position serving the Metro Area, with West Metro preferred. This position is available immediately and includes a $5,000 sign-on bonus. This is an excellent opportunity for an experienced home health nurse who values autonomy, flexibility, problem-solving, and strong communication, and who is confident managing a caseload and complex assessments independently in the field.

About Alliance Home Care

Alliance Home Care is a Minnesota-licensed home care agency providing skilled and non-skilled services to individuals in their homes and communities. Our team is dedicated to dignity, safety, and enabling clients to live independently with the support they need.

Position Summary

The Salaried RN Case Manager owns a caseload of home health patients across the Metro Area and is responsible for the full episode of care: completing Start of Care, Resumption of Care, and recertification assessments; establishing and revising the plan of care; and directing the interdisciplinary team assigned to each patient. All duties are performed in accordance with physician-ordered plans of care, the Minnesota Nurse Practice Act (Minn. Stat. ch. 148), Minnesota home care statutes (Minn. Stat. ch. 144A), and Medicare Conditions of Participation (42 CFR 484).

The RN Case Manager performs comprehensive patient assessments, identifies changes in condition, develops and updates individualized plans of care, coordinates with physicians and field clinicians, and ensures documentation is accurate, thorough, timely, and compliant with home health requirements. This role manages a self-directed field schedule and takes ownership of the accuracy and timeliness of the assessment that every subsequent visit depends on.

What We’re Looking For

We value nurses who are autonomous, resourceful, organized, and excellent communicators. Our ideal RN Case Manager is comfortable making clinical decisions in the field, knows when to escalate concerns, and takes ownership of ensuring patients receive the care and resources they need.

Primary Responsibilities

• Manage an assigned caseload of home health patients from admission through discharge.
• Complete Start of Care (SOC) assessments.
• Complete Resumption of Care (ROC) assessments.
• Complete recertification visits and assessments.
• Perform comprehensive patient assessments and identify changes in condition.
• Develop and update individualized plans of care.
• Coordinate care with physicians, field clinicians, patients, families, and the interdisciplinary team.
• Ensure documentation is accurate, thorough, timely, and compliant with home health requirements.
• Identify patient needs and proactively problem-solve barriers to care.

Essential Duties and Responsibilities

Case Management

• Serves as the primary clinical point of contact for an assigned caseload, maintaining accountability for patient outcomes across the certification period.
• Directs and coordinates the care provided by field clinicians, LPNs, home health aides, and therapy disciplines assigned to each patient on the caseload.
• Supervises LPNs and home health aides in accordance with the Minnesota Nurse Practice Act and Medicare supervisory visit requirements; completes required supervisory visits on schedule.
• Monitors visit utilization against the plan of care, identifies missed or at-risk visits, and adjusts scheduling and frequencies with the office team.
• Manages transitions of care, including hospital and facility admissions, resumptions, transfers, and discharge planning.
• Tracks certification periods, recertification windows, and expiring orders to prevent gaps in coverage or authorization.

Comprehensive Assessment and OASIS

• Completes the initial assessment visit, comprehensive assessment, and OASIS data collection within required timeframes (42 CFR 484.55); ensures OASIS accuracy and locks documentation per agency policy.
• Completes Resumption of Care assessments following inpatient stays and other qualifying events within required timeframes.
• Completes recertification assessments within the final five days of the certification period, in accordance with Medicare and agency policy.
• Performs comprehensive head-to-toe assessment, including functional status, cognitive status, medication review, fall and safety risk, wound and skin assessment, and pain evaluation.
• Verifies and documents homebound status, skilled need, and medical necessity at each assessment point.

Plan of Care Development and Management

• Develops, implements, and updates the individualized plan of care in collaboration with the physician/allowed practitioner, patient, family, and interdisciplinary team.
• Establishes visit frequencies, disciplines, orders, and goals that reflect the patient’s assessed needs and support appropriate resource utilization.
• Identifies changes in patient condition promptly and adjusts the plan of care, physician orders, and care team communications accordingly.
• Completes accurate diagnosis coding and sequencing to support the plan of care and the patient’s clinical picture.
• Obtains and clarifies physician orders as needed to establish or revise the plan of care.

Clinical Judgment in the Field

• Performs skilled nursing interventions during visits as ordered and within the Minnesota RN scope of practice.
• Conducts clinical observations including vital signs, cardiovascular and respiratory monitoring, medication reconciliation, and functional status.
• Recognizes when a patient’s condition requires escalation and communicates urgent findings to the physician and Director of Nursing without delay.
• Identifies patient needs and proactively problem-solves barriers to care, including equipment, supply, caregiver, and access issues.
• Provides compassionate, person-centered care that respects patient dignity, preferences, cultural background, and goals.

Patient and Family Education

• Introduces patients and family caregivers to the plan of care, visit expectations, and the roles of each member of the care team.
• Delivers individualized education covering disease management, medication regimens, treatment procedures, and home safety.
• Teaches patients to recognize and respond to signs and symptoms requiring prompt reporting or emergency intervention.

Care Coordination and Communication

• Communicates assessment findings, new orders, safety concerns, and newly identified needs to the Director of Nursing, physician, and assigned field clinicians promptly.
• Collaborates with physical, occupational, and speech therapists, social workers, the intake team, and community partners to establish coordinated, seamless care from the first visit forward.
• Coordinates with the scheduling and intake teams to accept referrals, meet assessment timeframes, and maintain continuity of care.
• Participates in case conferences, team meetings, and handoff communications as scheduled.

Documentation and Compliance

• Documents all visits, assessments, interventions, patient responses, and communications accurately and on time in the electronic health record (KanTime EMR) per agency and regulatory requirements.
• Ensures documentation supports homebound status, medical necessity, skilled need, and all billed services for Medicare and Medicaid claims (42 CFR 484.110).
• Completes visit documentation within 24–48 hours per agency standard; falsification of records is grounds for termination and may constitute fraud.
• Maintains compliance with CMS Conditions of Participation, the Minnesota Nurse Practice Act, Minnesota home care statutes, agency policies, and HIPAA.
• Serves as a mandated reporter of suspected maltreatment of vulnerable adults (Minn. Stat. 626.557) and minors (Minn. Stat. ch. 260E).
• Honors patient rights under 42 CFR 484.50 and the Minnesota Home Care Bill of Rights (Minn. Stat. 144A.44).
• Supports agency readiness for MDH home care licensing surveys and CMS certification audits.

Qualifications

• Current, unencumbered Minnesota RN license.
• Previous home health/home care experience required; two years of home care experience preferred.
• Experience completing SOCs, ROCs, and recertifications strongly preferred.
• Strong assessment and clinical documentation skills.
• Excellent communication and problem-solving abilities.
• Ability to independently manage a caseload and a field-based schedule.
• Reliable transportation and ability to travel throughout the Metro Area.
• Current Basic Life Support (BLS) / CPR certification.
• Valid driver’s license, acceptable driving record, and current auto insurance.
• Cleared Minnesota DHS background study (Minn. Stat. ch. 245C) prior to direct contact with patients.
• Tuberculosis screening consistent with MDH/CDC requirements prior to patient contact.

Preferred Qualifications

• Two or more years of home care or home health experience.
• Prior case management experience in a home health setting.
• OASIS experience or OASIS certification (COS-C).
• Experience with KanTime EMR or comparable home health documentation system.
• Familiarity with Minnesota home care regulations, the Home Care Bill of Rights, and PDGM.
• ICD-10 coding experience in a home health setting.
• Experience managing complex chronic conditions (CHF, COPD, diabetes, wound care, IV therapy) in a home or community setting.

Required Training (Provided or Verified by Alliance Home Care)

• Agency orientation, including the Minnesota Home Care Bill of Rights, patient rights, and agency policies prior to providing patient care.
• Vulnerable Adults Act and maltreatment mandated reporter training.
• Infection control, standard precautions, and HIPAA training.
• OASIS competency training prior to completing assessments independently.
• KanTime EMR documentation training prior to independent visits.
• Annual competency updates as required by agency policy and Minnesota home care regulations.
• Ongoing continuing education to maintain active RN licensure.

Physical Requirements

• Frequent travel between patient homes throughout the Metro Area; ability to operate a motor vehicle safely in varying weather conditions.
• Ability to lift, carry, push, or pull up to 50 pounds occasionally and up to 25 pounds frequently, consistent with safe patient handling and agency equipment policies.
• Frequent standing, walking, bending, stooping, kneeling, and reaching; performing clinical procedures in varied home environments, including confined spaces.
• Sufficient visual, hearing, and communication ability to observe patients, respond to calls for help, and communicate verbally and in writing.
• Manual dexterity sufficient to perform assessment, medication review, wound care, and EHR documentation.
• Potential exposure to communicable disease, bloodborne pathogens, household pets, variable home environments, and adverse weather during travel. PPE provided per agency policy.
• Ability to respond appropriately during patient emergencies.

Compensation & Benefits

• $90,000–$104,000 annual salary, based on experience
• $5,000 sign-on bonus
• Health insurance
• Dental insurance
• Vision insurance
• Short-term and long-term disability insurance
• Paid time off (PTO) and sick pay
• Travel stipend

Benefit eligibility varies based on employment status and length of service. Sign-on bonus terms, including payout schedule and any service commitment, will be provided in the written offer.

Schedule & Availability

Full-time, salaried. This position is available immediately. Visits are scheduled across the Metro Area, with West Metro preferred, and the RN Case Manager manages daily routing and visit sequencing independently within required OASIS timeframes. Caseload size, schedule expectations, and territory coverage will be reviewed during the interview process.

Why Alliance?

At Alliance Home Health Care & Nursing Services, we believe experienced home health nurses do their best work when they are trusted to use their clinical judgment. We value autonomy, accountability, communication, and practical problem-solving, and we want nurses who take pride in managing their patients and their work independently.

If you are an experienced home health RN looking for a role where your expertise, independence, and clinical judgment are genuinely valued, we’d love to hear from you.

Equal Opportunity Employer

Alliance Home Care is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees and the clients we serve. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, sexual orientation, gender identity, veteran status, or any other status protected by law.