Care Management Nurse; NY - REMOTE

Salary: $23.00/hr - $27.00/hr

Mobile Primary Care is a home-based primary care practice that specializes in geriatric healthcare, serving New York State.

A healthcare organization is seeking a licensed LVN, LPN or RN to join their growing staff as a new Care Management Nurse. This role will provide telephonic Care Management for patients throughout the health system under the direction of a patient’s provider. The nurse utilizes the nursing process to evaluate patient needs over the telephone and provide guidance and education to patients, adhering to organizational policies, procedures and guidelines.

Provides high‑risk patients with chronic disease management and liaises between the patient, patient’s family or caregiver, provider, provider’s office, hospital, home care agency, etc. This position is telephonic care coordination as directed by the patient’s provider.

• Cooperatively develop and integrate patient‑centered provider care plan and goals with the client/family and other providers
• Work collaboratively with team members to provide outreach and engagement with the patient
• Work closely with in‑office providers/staff members to provide patient education to assist with self‑management, identify gaps or barriers in treatment plans, coordinate care enrolled patients including scheduling appointments, coordinate referrals, and coordinate community resources as needed (e.g., home health, DME, etc.)
• Educate members on disease processes
• Encourage members to make healthy lifestyle changes
• Actively maintain assigned caseload of patients
• Make outbound calls to assess members’ current health status
• Receive and respond to telephone calls from patients, collecting health data and providing medical guidance under the direction of the patient’s provider
• Document calls according to established guidelines
• Connect patient’s care team together with updated information as received
• Participate in education and in‑service programs
• Perform on‑call for the region you are assigned
• Additional duties as assigned

• Unrestricted and current license to practice as LVN/LPN/RN with a New York State license
• 3 years of experience within a Care Management setting or as a Case Coordinator in homecare, inpatient, physician practice or in‑home case management setting
• Strong working knowledge of chronic disease states including chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease and congestive heart failure, and basic medical management of these states
• Highly motivated, result‑oriented with strong skills in presenting, communicating, organizing and time management
• Strong organizational and interpersonal skills
• Excellent customer service skills demonstrated by positive feedback from patients and team
• Ability to identify problems and recommend solutions
• Progressive proficiency with the utilization of available computer technology, including typing skills
• Leadership, communication, interpersonal and problem‑solving skills
• Experience working with an Electronic Health Record (EHR)
• Ability to sit and work at a computer for extended periods of time
• 60 words per minute typing

• Bilingual in Spanish