Virtual Registered Nurse (Care Manager) - Remote
SUMMARY: This is a remote RN Care Manager role focused on managing a panel of high-risk, post-discharge patients in the home health setting.
DUTIES: Manage and coordinate care for an assigned panel of approximately 80–100 high-risk post-discharge patients
Conduct initial patient assessments and develop individualized care plans following hospital discharge
Perform ongoing outbound follow-up calls and proactive patient outreach to monitor symptoms, identify risks, and prevent deterioration
Monitor complex clinical cases and escalate concerns to physicians, APPs, or appropriate team members when needed Re-engage in patient care for higher-level clinical concerns such as wound care issues, uncontrolled symptoms, medication concerns, or worsening conditions
Coordinate closely with Clinical Coordinators, Home Health field staff, physicians, pharmacists, and Care Navigators to ensure continuity of care Support transitions of care and reduce avoidable ER visits and hospital readmissions Identify social determinants of health and barriers to care impacting patient outcomes
Provide patient education, symptom management support, and guidance to help patients remain safely at home
Participate in interdisciplinary team meetings, case reviews, and weekly virtual collaboration discussions
Utilize technology platforms, analytics tools, and EMR systems to document care and identify patient risk in real time Ensure accurate, timely, and compliant documentation within the EMR
Support after-hours triage coverage on a voluntary stipend basis if participating in the triage rotation
Collaborate with assigned client organizations and participate in periodic in-person meetings, trainings, and quarterly team retreats as required
Contribute to the ongoing development and improvement of value-based care model
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