Home Nurse Care Manager

Home 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 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 :

Valued Qualifications :

Physical / Cognitive Requirements :

66,950 - $86,910 a yearThe United States new hire base salary target ranges for this full-time position are : Zone A : $66,850 - $86,910 equity benefitsThis range reflects the minimum and maximum target for new hire salaries for candidates based on their respective Zone. Below is additional information on Included Health's commitment to maintaining transparent and equitable compensation practices across our distinct geographic zones.Starting base salary for the successful candidate will depend on several job-related factors, unique to each candidate, which may include, but not limited to, education; training; skill set; years and depth of experience; certifications and licensure; business needs; internal peer equity; organizational considerations; and alignment with geographic and market data. Compensation structures and ranges are tailored to each zone's unique market conditions to ensure that all employees receive fair and competitive compensation based on their roles and locations. Your Recruiter can share details of your geographic alignment upon inquiry.In addition to receiving a competitive base salary, the compensation package may include, depending on the role, the following : Remote-first culture401(k) savings plan through FidelityComprehensive medical, vision, and dental coverage through multiple medical plan options (including disability insurance)Full suite of Included Health telemedicine ( behavioral health, urgent care, etc.) and health care navigation products and services offered at no cost for employees and dependentsGenerous Paid Time Off ("PTO") and Discretionary Time Off ("DTO")12 weeks of 100% Paid Parental leaveFamily Building Benefit with fertility coverage and up to $25,000 for Surrogacy & Adoption financial assistanceCompassionate Leave (paid leave for employees who experience a failed pregnancy, surrogacy, adoption or fertility treatment)11 Holidays Paid with one Floating Paid HolidayWork-From-Home reimbursement to support team collaboration and effective home office work24 hours of Paid Volunteer Time Off ("VTO") Per Year to Volunteer with Charitable Organizations

Salary : $66,950 - $86,910