Registered Nurse - Case Manager - South Philadelphia
Core
Lead care management activities and care coordination for complex patients in a value-based care environment to prevent avoidable admissions and ensure effective team-based care.
Role type
Senior Registered Nurse Case Manager
Builds
Care plans and transitions of care episodes for assigned patient panels
Domain
Healthcare / Geriatrics / Value-based care
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Care coordination, Patient education, Medication reconciliation, Transitions of care management, Interdisciplinary collaboration, Clinical assessments
Preferred skills
Transitional nursing, Emergency room nursing, Discharge planning, Home health, Motivational interviewing, Community resource navigation
Technologies
Electronic health record
Responsibilities
Manage assigned caseload of complex patients to drive reduced admissions and readmissions, Own overall care coordination as primary point of contact, Lead in-person interdisciplinary care planning meetings, Perform timely nursing assessments and provide patient education, Document visits in electronic health record, Collaborate with PCP, family, and specialists to evaluate needs and plan of action
Seniority
Senior, hands-on IC