Neighborhood Navigator Primary Care Nurse Practitioner - Manhattan (Bronx)

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