RN Nurse Care Manager – Hybrid

This is a fully remote position, open to applicants in Michigan.

📋 Description

• Oversee a caseload of high-risk patients and the barriers to their care.

• Conduct Transitional Care Management, Chronic Care Management, Disease Management Education, and Medication Education.

• Create and manage comprehensive patient care plans.

• Act as co-chair of the pod alongside the pod leader, concentrating on prioritizing patient needs and enhancing outcomes.

• Coordinate care services with the pod leader and the healthcare team.

• Identify and address care gaps, engaging resources to guarantee access to care.

• Manage transitions across the healthcare spectrum to help avert preventable hospital admissions.

• Lead High Risk Huddles and ensure that follow-up actions are carried out.

• Prioritize patients based on the severity of their conditions and urgency.

• Examine medical records to pinpoint gaps in care.

• Conduct telephone nursing assessments.

• Provide education to patients and caregivers on disease management, medication, health maintenance, and prevention strategies.

• Record interactions, assessments, and updates in medical records.

• Serve as a liaison between patients, providers, and available resources.

• Communicate patient status and care plans during transitions among home, hospital, post-acute care, and back home.

⛳️ Requirements

• Valid Registered Nurse License.

• Minimum of 2 years of care management experience in community, health plan, or hospital settings.

• Strong clinical skills and proactive approach to problem-solving.

• Excellent communication abilities.

• Capable of performing thorough telephone assessments.

• Familiarity with Medicare regulations and standards for home care and hospice.

• Experience in delivering small group presentations and in teaching/training roles.

• Outstanding interpersonal skills.

• Proficient in written and oral communication.

• Competent in utilizing computer programs (email, Word, Excel, PowerPoint, etc.).

• Efficient time management skills to ensure all responsibilities and documentation are completed promptly.

• May need to obtain multi-state licensing.

• Preferred: Bachelor of Science in Nursing or a related field.

• Preferred: In-depth knowledge of population health, quality measures, care gap closure, and value-based care models.

🏝️ Benefits

• Quarterly Bonuses.

• Health, Dental, Vision, Disability & Life Insurance.

• 401K Retirement Plan (with company match).

• Tuition, Professional License, and Certification Reimbursement.

• Paid Time Off, Holidays, and Volunteer Time Paid.

• Orientation and Training during Daytime Hours (no holidays/weekends).