RN Nurse Care Manager

• Manage a caseload of high-risk patients and their care barriers
• Perform Transitional Care Management, Chronic Care Management, Disease Management Education, and Medication Education
• Develop and manage patient care plans
• Serve as co-chair of the pod alongside the pod leader, focusing on prioritizing patient needs and improving outcomes
• Coordinate care services to ensure patients access comprehensive services tailored to their needs
• Collaborate with the care team to address care gaps and engage resources
• Coordinate transitions of care and help prevent avoidable hospital admissions
• Coordinate and facilitate High Risk Huddles and ensure follow-up actions are completed
• Prioritize patients according to condition severity and urgency
• Review medical records to identify gaps in care and coordinate services
• Conduct telephone nursing assessments
• Educate patients and caregivers on disease, medication, health maintenance, and prevention
• Document interactions, assessments, and updates in medical records
• Serve as liaison between patients, providers, and resources
• Facilitate communication of patient status and care plans during transitions between home, hospital, post-acute care, and home

• Active Registered Nurse License
• 2+ years of care management experience in community, health plan or hospital systems
• Possesses strong clinical skills and proactive thinking
• Effective communication skills
• Ability to perform extensive telephone assessment
• Knowledge of Medicare regulations and home care and hospice standards
• Experience with small group presentations and teaching/training
• Exhibits excellent interpersonal skills
• Exhibits excellent written and oral skills
• Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.)
• Manages time effectively to ensure all duties and documentation requirements are completed in a timely manner
• May be required to obtain multi-state licensing
• Preferred:
  Bachelor of Science in nursing or related field
• Preferred:
  Strong knowledge of population health, quality measures, care gap closure and value-based care models

Demonstrates expertise in care management, including Transitional Care Management, Chronic Care Management, and Disease Management Education, while effectively coordinating patient care and collaborating with healthcare teams. Strong clinical skills and knowledge of Medicare regulations enhance the ability to improve patient outcomes and manage high-risk cases.

• Active Registered Nurse License
• Care Management Experience
• Clinical Skills
• Knowledge of Medicare Regulations
• Population Health Knowledge

• Transitional Care Management
• Chronic Care Management
• Disease Management Education
• Medication Education
• Telephone Nursing Assessment
• Patient Care Plan Development
• Medical Record Review
• Care Coordination
• Time Management
• Teaching/Training

• Effective Communication Skills
• Interpersonal Skills
• Proactive Thinking
• Written and Oral Skills

• Registered Nurse License
• Multi-State Licensing (if required)

• High-Risk Patients
• Care Gaps
• Value-Based Care Models
• Quality Measures
• Home Care Standards
• Hospice Standards

• Email
• Word
• Excel
• Power Point