Job Description
About Us
We are a community-focused organization dedicated to improving the health and well-being of those who need it most. Our mission is to remove barriers to care and provide services as close to home as possible, including in-home care when feasible.
We understand that effective healthcare takes into account race, culture, and environment. We are committed to building a culture of care that starts with truly understanding our patients, their needs, and their care plans.
Our approach centers on local physicians, nurses, and caregivers, offering personal care and services that address the needs of individuals, not just symptoms of illness. By focusing on in-home care whenever possible, we aim to deliver better outcomes for individuals and their communities.
We are driven by a deep commitment to improving the health of underserved populations, and we believe that providing care is a privilege we are grateful to earn. Our goal is to create a world where health and care are not burdens, but accessible and supportive aspects of daily life. We are determined to make a difference, one community at a time.
About the Role
We are looking for a compassionate and experienced RN Case Manager to join our team. This role involves providing strategic guidance, organization, and evidence-based analysis to meet our care requirements and improve patient outcomes.
Key Responsibilities:
Work as part of an interdisciplinary team to ensure high-quality outcomes for members/families managing chronic diseases.
Develop care pathway templates and member action plans using alert-driven systems.
Implement remote patient monitoring and self-reporting for high-risk chronic conditions.
Conduct in-home or tele-health assessments as needed.
Respond to real-time alerts and maintain active communication with members and caregivers via text and phone.
Coordinate care, including navigation, chronic disease management, and interdisciplinary collaboration, while adhering to policies and procedures.
Engage patients in proactive health management and refer them to community-based organizations or programs as needed.
Follow evidence-based guidelines to address gaps in care and determine when in-home services are required.
Use electronic medical records and care management platforms for coordination and documentation.
Participate in team-based rounds for program development and process improvement.
Reassess Member Action Plans post-discharge and adjust priorities as needed.
Qualifications:
Active state Registered Nursing license and a BSN degree.
At least 5 years of clinical experience, with a preference for 3+ years in care management within health plans, home health, or hospice.
Ability to work independently, initiate change, and innovate within the role.
Excellent communication skills, both verbal and written.
Ability to build and manage relationships with patients, community leaders, and external partners.
Strong judgment, ethics, and a collaborative team spirit.
Additional Duties:
Lead in defining and executing strategies to enhance clinical practice and deliver business value.
Develop business strategies to improve member outcomes and enhance organizational efficacy.
Collaborate with other business divisions to ensure cohesive clinical offerings and solutions.
Provide subject matter expertise in clinical solutions and care management.
Foster a productive, collaborative, and inclusive work environment.
Working Environment:
This role involves both in-home and office-based work, with frequent travel for home visits and visits to physician offices, hospitals, and community partners.
Requires the ability to travel by car or public transportation, communicate effectively, and occasionally lift up to 30 lbs.
Proficiency with office equipment and a good reasoning ability for managing reports and documents are essential.
Employment Type: Full-Time
Salary: $ 85,000.00 90,000.00 Per Year
Job Tags
Full time, Local area, Home office,