Home Based Nurse Care Manager

Home Based Nurse Care Managers provide comprehensive, in-home care management services to high-risk patients. This role focuses on preventing hospital readmissions, improving health outcomes, and ensuring patients receive the support and resources they need to manage their conditions effectively. The Nurse Care Manager will work closely with patients, their families, and other healthcare providers to develop and implement personalized care plans that address each patient's unique needs. 
Home Based Nurse Care Manager will work directly with members in their local communities to bring better health and quality of life to these individuals and families.  They will be a part of an integral team including a Community Health Worker and an Included Health Virtual PCP.

Responsibilities:

• Conduct in person visits to assess patient health status, educational, and psychosocial needs of the patient and their family. This will be at patient’s homes, hospitals, or accompanying to medical appointments.
• Together with patients and our multidisciplinary care team, generate a comprehensive individualized plan of care and targeted interventions to help patients achieve desired goals
• Provide education and support to patients and families on managing chronic conditions, medications, and lifestyle changes
• Identify and address barriers to care, including social determinants of health, and connect patients with community resources and support services with the support of a remote Licensed Social Worker and Local Community Health Worker.
• Collaborate with patients, the remote Included Heath team, community physicians, family members, and other members of the health care team in order to ensure coordinated care.
• Continually monitor patient response to the plan of care, and revise the care plan as indicated.
• Implement systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.
• Maintain required documentation for all care management activities.
• Participate in case conferences and care coordination meetings to ensure a holistic approach to patient care.
• Participate in member engagement initiatives, including outreach to local provider and hospital groups.
• Stay current with best practices and evidence-based guidelines in chronic disease management and care coordination.
• Provide compassionate, longitudinal follow-up care, building supportive relationships.
• Assist throughout acute healthcare episodes, such as hospitalizations and rehabilitation stays, providing coordinated Case Management to support the member and their family.

As a condition of employment, the successful applicant for this position must be fully vaccinated against COVD-19 and flu (including annual booster) and provide acceptable proof of vaccination against Hepatitis B, Varicella, and MMR.
In accordance with its policies, Included Health provides reasonable accommodations, absent undue hardship, to those who are unable to be vaccinated, either because of a sincerely held religious belief or a disability. If granted a reasonable accommodation from a vaccination requirement, the successful applicant will be required to be masked when providing services within patients' homes.

Required Qualifications:

• Current Bachelor of Science in Nursing (BSN)
• Must reside in  and have an active RN license in good standing with your state (AZ, TX, or IL) medical board
• BLS certification
• Current driver’s license, reliable transportation, car insurance, and an acceptable driving record with willingness to travel within approximately 50 miles to meet in person with patients in their homes or other medical facilities including hospitals, and local physician offices.
• 2+ years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting, within the past five years 
• Strong clinical assessment, physical exam, and critical thinking skills. Comfortable discussing a wide variety of medical conditions.
• Broad knowledge of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and patient education 
• Demonstrate excellent communication--both verbal and written. Proficient at writing medical information in easy-to-understand, patient-centric language. 
• Able to work independently with strong internal drive, yet able to actively communicate challenges and/or concerns to leadership.
• Excellent interpersonal and facilitation skills
• Excellent time-management skills and an ability to adapt to changing needs/priorities 
• Be highly empathetic with the ability to understand cultural and socioeconomic issues affecting patients and excellent at building rapport wit