Nurse Care Manager (Evergreen)

Must have reliable access to high-speed internet. Current Registered Nurse license in Michigan and/or New York. Willing and able to obtain additional state nursing license(s) if needed. Bachelor’s of Science in Nursing preferred. Certified Case Manager (CCM) credential preferred. 3+ years of clinical practice in a hospital, clinic, home care, or nursing home setting highly preferred. Case management experience with a senior population preferred. Disease management and/or physician office experience highly preferred. Prior experience with electronic health records or health registries required. Microsoft Office skills, including Excel, Word, PowerPoint, Outlook required.

Manage patients' specialized needs based on individual condition and recent utilization. Take ownership of assigned patients with complex chronic conditions, serious illness, or recent healthcare utilization. Develop effective and comprehensive plans of care based on patient assessments and values. Coordinate patient care delivery with clinicians, network providers, vendors, and community services. Monitor care and identify cost-effective measures. Coordinate patient admissions and discharges from facilities. Build relationships across network hospitals, SNFs, home health companies, and DME vendors. Monitor and evaluate the effectiveness of case management plans. Coordinate the interdisciplinary approach to continuity of care. Act as a patient advocate and educator. Develop individualized patient/family education plans. Engage internal resources to identify and respond to social determinants of health. Participate in data collection and analysis of clinical outcomes. Maintain accurate patient care records. Participate in huddles, interdisciplinary team sessions, and patient case conferences. Represent Honest Health to patients, families, and the community.