RN Care Manager

RN Care Manager

U.S. Medical Management (USMM), an affiliate of a leading Fortune 250 company, manages a nationwide continuum of premier providers of medical services delivered primarily to the homes of elderly and homebound patients. Providing primary home care is the future of medicine, and at USMM, the future is now. With the knowledge and experience to address the evolution of healthcare, USMM is poised for a phenomenal future.


Under general direction, this position will be responsible for a panel of patients who exhibit unique problems affecting utilization, quality, or cost. Through a process of outreach and coordination, the Care Manager will coordinate care between hospital transitions, including home or other post-acute Providers. Additionally, the Care Manager will act as a resource and advocate on behalf of the patient and family while assisting the navigation of the health care delivery continuum. The Care Manager will assist in providing goal based interventions and enhance an organized system of care delivery.


* Coordinating services to ensure the patient/family understands the treatment plan

* Provide outreach to community based services to support the patients ability to age at home

* Develop and implement shared goals of care with the patient and family

* Conducting telephonic outreach to the patient and/or caregiver

* Provide feedback to the home based primary care physician (HBPCP) to ensure he/she is aware of any early patient changes

* Conduct outreach and coordination of discharge planning with local hospitals and post-acute Providers to ensure that patients stay aligned with their HBPCP

* Lead or participate in Multidisciplinary Care Planning Rounds

* Conduct additional psycho-social assessments as patient needs change

* Work with Community based agencies to develop relationships and provide appropriate resources to assist in maintaining patient independence

* Early identification of patients who may reach eligibility for Independence at Home Programs

* Other duties/projects as assigned


* Minimum of 3 years of experience in Care Management in hospital or managed care setting

* Self-directed with excellent problem solving skills

* Ability to multitask while maintaining professionalism

* Current unrestricted Registered Nurse License

* Excellent verbal and written communication skills

* Excellent computer skills


* Bachelor's Degree in Nursing