About the Role
This role involves conducting clinical evaluations, managing patient cases in home and community settings, and coordinating care across providers to improve health outcomes and adherence to treatment plans.
Responsibilities
- Perform in-home patient assessments to evaluate medical needs
- Develop individualized care management plans
- Monitor patient progress and adjust interventions as needed
- Collaborate with physicians and specialists on treatment strategies
- Ensure compliance with clinical protocols and documentation standards
- Coordinate referrals to specialists and community resources
- Educate patients and families on disease management
- Track patient outcomes using electronic health records
- Conduct follow-up visits to assess treatment effectiveness
- Support transitions of care between facilities and home
- Identify barriers to care and recommend solutions
- Maintain accurate and timely case notes
- Participate in care team meetings and case reviews
- Respond to urgent patient situations as needed
- Ensure adherence to privacy and HIPAA regulations
- Assist in discharge planning from hospitals or clinics
- Promote preventive care and wellness initiatives
- Manage high-acuity and chronic care cases
- Provide clinical guidance to non-medical staff when required
- Stay current with best practices and clinical guidelines
Benefits
- Health, dental, and vision insurance
- Retirement savings plan with employer contribution
- Paid time off and paid holidays
- Flexible spending accounts
- Professional development opportunities
- Life and disability insurance
- Employee assistance program
- Continuing education reimbursement
- Mobile device and internet stipend
- Mileage reimbursement for work-related travel
Compensation
Competitive hourly rate based on experience
Work Arrangement
Hybrid role with field and remote components
Team
Part of a multidisciplinary care coordination team
About the Role
This position serves as a bridge between clinical care and community support, focusing on improving patient outcomes through proactive case management and direct field engagement.
What We’re Looking For
We seek a compassionate, detail-oriented nurse with a strong clinical background and a commitment to equitable, high-quality patient care in diverse urban settings.
Not available for this position
