Home-Based RN Care Manager for Complex Patient Care

MyCare Medical Group; Florida; On-site; USD 90,000 - 100,000; Full time

Benefits offered by this job

Competitive compensation

Comprehensive benefits

Job summary

MyCare Medical Group in Palm Beach Gardens, FL, is seeking a full-time RN Care Manager to perform in-home care coordination and case management for patients with complex needs. The role emphasizes social determinants of health, community resource navigation, and interdisciplinary collaboration.

The RN must be an active Florida licensed nurse with 2+ years of nursing experience, including case management or home health; BLS is required and travel is expected within the service area.

Qualifications

• Active, unrestricted RN license in Florida.
• Minimum 2 years of nursing experience.
• At least 1 year of experience in case management, home health, community health, public health, care coordination, or related setting preferred.
• Experience with Medicare Advantage, seniors, chronically ill, or medically complex populations preferred.
• Knowledge of Social Determinants of Health (SDOH) and community resources.
• Strong care coordination, communication, organization, and critical-thinking skills.
• Ability to work independently while collaborating with an interdisciplinary care team.
• Current BLS certification required.
• Valid Florida driver’s license, reliable personal vehicle, and current automobile insurance required.
• Ability and willingness to travel regularly for in-home patient visits throughout the assigned service area.

Responsibilities

• Conduct comprehensive clinical, environmental, and psychosocial assessments in patients' homes and community settings.
• Identify barriers to care, including housing, food insecurity, transportation, medication access, and social support.
• Develop, implement, and regularly update individualized patient-centered care plans.
• Coordinate care between patients, primary care providers, specialists, social workers, home health agencies, and other members of the interdisciplinary team.
• Connect patients and families with appropriate community resources and social services.
• Support patients with transitions of care, hospital discharges, and follow-up appointments to promote continuity and reduce avoidable hospitalizations.
• Educate patients and caregivers on disease management, medications, treatment plans, preventive care, and self-management strategies.
• Monitor patient progress and follow up on identified clinical and social needs.
• IV therapy and medication management
• Laboratory coordination
• Advocate for patients and help overcome barriers that may negatively impact health outcomes.
• Maintain accurate and timely documentation of assessments, care plans, interventions, and patient outcomes.
• Collaborate with providers and interdisciplinary teams to ensure patients receive appropriate and coordinated care.
• Promote patient engagement, adherence, and improved overall health outcomes.

Skills

RN license

Care coordination

Home health

Medicare Advantage experience

SDOH knowledge

Communication

Organization

Critical thinking

Travel willingness

Job description

MyCare Medical Group in Palm Beach Gardens, FL, is seeking a full-time RN Care Manager to perform in-home care coordination and case management for patients with complex needs. The role emphasizes social determinants of health, community resource navigation, and interdisciplinary collaboration.

The RN must be an active Florida licensed nurse with 2+ years of nursing experience, including case management or home health; BLS is required and travel is expected within the service area.