The RN Care Manager is responsible for providing comprehensive, member-centered care coordination and management across clinical, psychosocial, financial, and environmental domains. This role involves assessing and addressing the diverse needs of members across varying ages, risk levels, and cultural backgrounds. The Care Manager engages members in collaborative relationships to empower self-management of chronic conditions and overall well-being.

Manage a caseload of 80-100 members - most likely right around 80

Population - US Veterans current or former + eligible family members

Hours: M-F: 9am - 5pm

HYBRID model - Monday/Friday - Remote | Tues-Thurs in office (Manhattan)

Pay: 110,000

3-5 Must Have Skills/Qualifications

• BSN
• Minimum of 2 years Care management experience
• Medical Surgical Nursing experience
• Licensed in NY and open to licensing in PA, NJ, CT

Overview

• Assess and address members' clinical, psychosocial, financial, and other needs.
• Deliver care and support to members across diverse ages, risk levels, cultural backgrounds, and socioeconomic conditions.
• Build collaborative relationships with members to encourage self-management of their health and overall well-being.
• Develop personalized care plans with input from members, caregivers, and healthcare providers, incorporating cultural sensitivity and privacy standards.
• Actively participate in interdisciplinary team meetings to coordinate comprehensive care.
• Create care plans with clearly defined, individualized goals and targeted interventions.
• Communicate care plans and updates with primary care physicians and medical specialists to ensure alignment.
• Identify and address gaps in care through collaboration with members, caregivers, and providers.
• Evaluate and respond to social determinants of health that impact member outcomes.
• Connect members with appropriate community-based services and resources.
• Provide care management support during transitions between healthcare settings to maintain continuity of care.
• Ensure members and caregivers fully understand care instructions, taking into account language, cognitive, and emotional barriers.
• Educate members on chronic disease management, preventive health, medication safety and adherence, and home safety strategies.
• Deliver complex care management, including facilitating access to care, reducing avoidable hospitalizations, and coordinating community referrals.
• Advocate on behalf of members to help them navigate challenges and make informed healthcare decisions.

• Document all clinical and non-clinical interactions accurately and promptly in the system