In Home Complex Care Nurse Care Manager
Core
Provide comprehensive in-home care management for high-risk patients to prevent hospital readmissions and improve health outcomes.
Role type
Senior IC nurse care manager (complex care)
Builds
Individualized care plans and targeted interventions for high-risk members
Domain
Healthcare / Chronic disease management / Home health
Deliverable
physical/clinical work
Required skills
Clinical assessment, physical exam, critical thinking, chronic condition management, patient education, care coordination, documentation, cultural competency
Preferred skills
Spanish fluency, CCM certification, remote team experience, weekend availability
Technologies
Electronic health records, care management software
Responsibilities
Conduct in-person home visits to assess patient health and psychosocial needs; Develop and implement personalized care plans with multidisciplinary teams; Educate patients and families on chronic conditions and medication management; Connect patients with community resources to address social determinants of health; Monitor patient response and revise care plans as needed; Coordinate care during acute episodes like hospitalizations; Maintain required documentation for all care activities.
Seniority
Mid-level, hands-on IC
