In Home Complex Care Nurse Care Manager

Job Description

Job Description

In Home Complex Care Nurse Care Manager 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. 

In Home Complex Care 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.

This role plays a crucial role within the Clinical team, reporting directly to the Clinical Care Manager.

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.

For candidates in TX: As a condition of employment, the successful applicant for this position must be fully vaccinated against the flu (including annual booster) and provide acceptable proof of vaccination against Hepatitis B, Varicella, and MMR. Although not required, Included Health highly encourages the successful applicant to be fully vaccinated against COVID-19 (including annual booster). 

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:

• Current Bachelor of Science in Nursing (BSN)

• Must reside in San Antonio, TX area and have an active RN license in good standing with TX

• BLS certification

• Current driver’s license, reliable transportation, car insurance, and an acceptable driving record with willingness to travel within approximately 50 miles to meet in person with patients in their homes or other medical facilities including hospitals, and local physician offices.

• 2+ years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting, within the past five years 

• Strong clinical assessment, physical exam, and critical thinking skills. Comfortable discussing a wide variety of medical conditions.

• Broad knowledge of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and patient education 

• Demonstrate excellent communication--both verbal and written. Proficient at writing medical information in easy-to-understand, patient-centric language. 

• Able to work independently with strong internal drive, yet able to actively communicate challenges and/or concerns to leadership.

• Excellent interpersonal and facilitation skills

• Excellent time-management skills and an ability to adapt to changing needs/priorities 

• Be highly empathetic with the ability to understand cultural and socioeconomic issues affecting patients and excellent at building rapport with patients and families from diverse backgrounds.

Valued Qualifications:

• IL & AZ Licensure

• Current CCM Certification (in states where not required)

• 5+ years of experience in nursing 

• Comfortable with technology and experience working remotely or with innovative care teams

• Experience working with patients in their homes

• Bilingual: Spanish and English

• Ability to have flexible schedule, position may require weekend work

Physical/Cognitive Requirements:

• Driving to member’s homes up to 5 days per week over wide geographical area

• Prompt and regular attendance at assigned work location.

• Ability to remain seated in a stationary position for prolonged periods.

• Requires eye-hand coordination and manual dexterity sufficient to operate keyboard, computer and other office-related equipment.

• No heavy lifting is expected, though occasional exertion of about 20 lbs. of force (e.g., lifting a computer / laptop) may be required.

• Ability to interact with leadership, employees, and members in an appropriate manner.

The duties and responsibilities in this job description are neither exclusive nor exhaustive and will be updated on a regular basis and may be amended in the light of changing circumstances or business needs. While this job description is intended to be an accurate reflection of the current job, Included Health reserves the right to add, modify, or exclude any duty or requirement at any time or without any notice. Finally, this job description is not intended in any way to create a contract of employment. Unless you have a written employment agreement signed by an authorized Included Health or Doctor On Demand representative, you are employed at-will.

The United States new hire base salary target range for this full-time position is:

$74,810 - $104,730 + equity + benefits

This 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 you will depend on several job-related factors, unique to each candidate, which may include education; training; skills; years and depth of experience; certifications and licensure; our needs; internal peer equity; organizational considerations; and understanding of 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 great compensation package based on their roles and locations. Your Recruiter can share your geographic zone upon inquiry.

Benefits & Perks:

In addition to receiving a great compensation package, the compensation package may include, depending on the role, the following and more:

Remote-first culture

401(k) savings plan through Fidelity

Comprehensive medical, vision, and dental coverage through multiple medical plan options (including disability insurance)

Paid Time Off ("PTO") and Discretionary Time Off ("DTO")

12 weeks of 100% Paid Parental leave

Family Building & Compassionate Leave: Fertility coverage, $25,000 for surrogacy/adoption, and paid leave for failed treatments, adoption or pregnancies.

Work-From-Home reimbursement to support team collaboration home office work

Your recruiter will share more about the salary range and benefits package for your role during the hiring process.

About Included Health

Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We’re on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community — no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It’s all included. Learn more at   includedhealth.com.

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Included Health is an Equal Opportunity Employer and considers applicants for employment without regard to race, color, religion, sex, orientation, national origin, age, disability, genetics or any other basis forbidden under federal, state, or local law. Included Health considers all qualified applicants with arrest or conviction records in accordance with the San Francisco Fair Chance Ordinance, the Los Angeles County Fair Chance Ordinance, and California law.

Included Health uses AI-assisted tools at select stages of the hiring process to enhance efficiency, consistency, and communication. AI does not make hiring decisions—final decisions are made exclusively by our recruiting and hiring teams.