Remote RN Care Manager for Complex Patients

Family Health Center Of M; United States; Remote; USD 39,000 - 55,000; Part time

Job summary

Family Health Center Of M is seeking an RN Care Coordinator to lead care planning for patients with complex medical and social needs. The role emphasizes holistic assessment, patient education, and empowerment under an interdisciplinary team.

You will manage a caseload, conduct assessments, and coordinate transitions of care to reduce hospital utilization while ensuring high-quality, patient-centered service delivery.

Qualifications

• Associate’s degree in nursing.
• Minimum of three years of recent clinical experience in a hospital or clinic setting working with adult patients.
• Proficient in the use of computers and electronic health record systems in a clinical setting.
• Bachelor of Science in Nursing (BSN) preferred.
• Bilingual in English and Spanish preferred.

Responsibilities

• Develops, implements, coordinates, and evaluates individualized healthcare plans in collaboration with interdisciplinary teams to improve access, reduce hospitalizations, and ensure quality care delivery.
• Collaborates with providers and practice staff to identify appropriate patients for care management, utilizing established program criteria.
• Performs comprehensive initial and periodic assessments, collecting relevant data on the patient’s health status and prioritizing patients based on intensity, need, and required follow-up.
• Formulates and implements care management plans that address patient/family needs, resources, and goals; educates patients and families on care choices and supports informed decision-making.
• Establishes mutually agreed-upon care plans with patients, families, and care teams that include clear, action-oriented self-management goals.
• Evaluates the effectiveness of care plans, revising as needed to address evolving needs, goals, and barriers, monitors and documents patient progress.
• Coordinates multidisciplinary care conferences to address patient progress, emerging issues, and shared team responsibilities.
• Promotes patient self-management and engagement to achieve optimal wellness and independence through education and support.
• Conducts post-discharge follow-up calls for high-risk patients recently hospitalized or treated in emergency departments to ensure safe and effective transitions of care.

Skills

Care coordination

Communication

Telephone follow-up

Bilingual English/Spanish

Nursing

Education

Associate degree in nursing

BSN preferred

Tools

EMR systems

Microsoft Office

Job description

Family Health Center Of M is seeking an RN Care Coordinator to lead care planning for patients with complex medical and social needs. The role emphasizes holistic assessment, patient education, and empowerment under an interdisciplinary team.

You will manage a caseload, conduct assessments, and coordinate transitions of care to reduce hospital utilization while ensuring high-quality, patient-centered service delivery.