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San Antonio, Texas, United States
Hybrid
In Home Complex Care Nurse Care Manager 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.
In Home Complex Care 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.
This role plays a crucial role within the Clinical team, reporting directly to the Clinical Care Manager.
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.
Current Bachelor of Science in Nursing (BSN)
Must reside in San Antonio, TX area and have an active RN license in good standing with TX
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 with patients and families from diverse backgrounds.
IL & AZ Licensure
Current CCM Certification (in states where not required)
5+ years of experience in nursing
Comfortable with technology and experience working remotely or with innovative care teams
Experience working with patients in their homes
Bilingual: Spanish and English
Ability to have flexible schedule, position may require weekend work
Driving to member’s homes up to 5 days per week over wide geographical area
Prompt and regular attendance at assigned work location.
Ability to remain seated in a stationary position for prolonged periods.
Requires eye-hand coordination and manual dexterity sufficient to operate keyboard, computer and other office-related equipment.
No heavy lifting is expected, though occasional exertion of about 20 lbs. of force (e.g., lifting a computer / laptop) may be required.
Ability to interact with leadership, employees, and members in an appropriate manner.
The duties and responsibilities in this job description are neither exclusive nor exhaustive and will be updated on a regular basis and may be amended in the light of changing circumstances or business needs. While this job description is intended to be an accurate reflection of the current job, Included Health reserves the right to add, modify, or exclude any duty or requirement at any time or without any notice. Finally, this job description is not intended in any way to create a contract of employment. Unless you have a written employment agreement signed by an authorized Included Health or Doctor On Demand representative, you are employed at-will.
