ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.
Other duties may be assigned.
• Manages a caseload of an assigned panel of chronic care patients, including patients with mental health issues.
• Collaborates with physicians, providers, and practice staff in identifying appropriate patients for care management.
• Develops relationships with patients as an integral member of the team.
• Provides follow-up management with patients to ensure compliance with their individual care plan.
• Maintains availability to provide telephone advice per protocol, and handles urgent and emergency calls during working hours.
• Anticipates the needs of the patient population, seeing that necessary documentation and pre-visit planning is completed or requested before patient visit.
• Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.
• Determines and coordinates appropriate referrals as needed.
• Works with patients and patient’s care team to coordinate change readiness, needs assessment and to develop an individualized treatment care plan.
• Collaborates with the patient, physician, and other care team members in assessing the patient’s progress toward individual health care goals.
• Maintains accessible, consistent documentation of patient self-management measures, and reporting progress toward goals.
• Assists patients in setting SMART goals for self-management, teaching them how to do self-management tasks, and reports abnormal findings to their physician team.
• Assesses barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments.
• Participates in regular team meetings and peer review activities.
• Promotes collaborative teamwork and is able to work with peers in a team situation.
• Collaborates with payer Case Managers for additional services when appropriate.
• Maintains a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently.
• Makes recommendations for policies/procedures to ensure that preventive services are offered in a timely manner to all who qualify.
• Provides follow-up in the transitions of care from various settings (hospital or skilled nursing facility discharges and emergency room visits).
• Coordinates disease registry activities.
• May conduct home visits with a physician in order to assess safety, medication compliance, and home environment.
• Participates in departmental and organizational committees as applicable.
QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job.
KNOWLEDGE, EDUCATION AND/OR EXPERIENCE: The Case Manager must have knowledge of the Patient-Centered Medical Home model/mission as well as knowledge of insurance industry practices and requirement. He/she must have an understanding of chronic disease and preventive care measures. Must have a bachelor’s degree in health care administration, health informatics, or a related field and hold licensure as a Licensed Practical Nurse, or an incumbent holding licensure as a Licensed Practical Nurse and having significant experience in chronic care may be considered. Licensure as a Registered Nurse is preferred. Experience working with patients with mental health issues is preferred.
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ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.
Other duties may be assigned.
• Manages a caseload of an assigned panel of chronic care patients, including patients with mental health issues.
• Collaborates with physicians, providers, and practice staff in identifying appropriate patients for care management.
• Develops relationships with patients as an integral member of the team.
• Provides follow-up management with patients to ensure compliance with their individual care plan.
• Maintains availability to provide telephone advice per protocol, and handles urgent and emergency calls during working hours.
• Anticipates the needs of the patient population, seeing that necessary documentation and pre-visit planning is completed or requested before patient visit.
• Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.
• Determines and coordinates appropriate referrals as needed.
• Works with patients and patient’s care team to coordinate change readiness, needs assessment and to develop an individualized treatment care plan.
• Collaborates with the patient, physician, and other care team members in assessing the patient’s progress toward individual health care goals.
• Maintains accessible, consistent documentation of patient self-management measures, and reporting progress toward goals.
• Assists patients in setting SMART goals for self-management, teaching them how to do self-management tasks, and reports abnormal findings to their physician team.
• Assesses barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments.
• Participates in regular team meetings and peer review activities.
• Promotes collaborative teamwork and is able to work with peers in a team situation.
• Collaborates with payer Case Managers for additional services when appropriate.
• Maintains a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently.
• Makes recommendations for policies/procedures to ensure that preventive services are offered in a timely manner to all who qualify.
• Provides follow-up in the transitions of care from various settings (hospital or skilled nursing facility discharges and emergency room visits).
• Coordinates disease registry activities.
• May conduct home visits with a physician in order to assess safety, medication compliance, and home environment.
• Participates in departmental and organizational committees as applicable.
QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job.
KNOWLEDGE, EDUCATION AND/OR EXPERIENCE: The Case Manager must have knowledge of the Patient-Centered Medical Home model/mission as well as knowledge of insurance industry practices and requirement. He/she must have an understanding of chronic disease and preventive care measures. Must have a bachelor’s degree in health care administration, health informatics, or a related field and hold licensure as a Licensed Practical Nurse, or an incumbent holding licensure as a Licensed Practical Nurse and having significant experience in chronic care may be considered. Licensure as a Registered Nurse is preferred. Experience working with patients with mental health issues is preferred.
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GENERAL JOB SUMMARY
An exempt clinical position where the nurse practitioner (NP) is responsible for providing direct patient care. The NP participates as a leader of the skilled nursing facility (SNF) care team. Visits managed care and fee-for-service patients at skilled and long-term levels of care in designated SNFs facilities. Provides appropriate evidence-based geriatric medicine. Coordinates care with hospitalists, primary care physicians and care managers. Makes home visits as directed by the medical staff to meet patient needs and provide continuity of care.
ESSENTIAL JOB FUNCTIONS
Maintains privileges in multiple Nursing Homes as directed by ACAMaintains license and malpractice insuranceConsults supervising attending as neededDocuments patient visits electronically at least 90% of the timeParticipates in documentation and other quality improvement programsAvailable via phone weekdays 8am- 7pm and when on call.Will reviews, approves, and modifies admission ordersCreates a detailed admit note for each admission within 24 hours of patient admission to SNF, including medication reconciliationInitiates/documents Advanced DirectivesDetermines if Health Care Proxy status is correct and invoke if appropriateOn weekends, takes call for admissions and see new patients within 24 hours of admission on a rotating basis with other practitioners in the program.
Daily Visits
Initiates and review orders, including medications, on a daily basisReviews labs, radiology reports, and consults on all patientsTalks to and examines each assigned skilled-level patient on daily rounds Monday through FridayWrites at least one daily progress note for each skilled patientAssess patient’s medical stability daily. Consults/coordinates with specialists as neededAddresses acute mental status changes via non-pharmacologic or pharmacologic measures, consultation or transferCoordinates/assess rehab progress on a daily basisDiscusses concerns with the patient, family, rehab, and case management. Educates patient and family members regarding acute and chronic illness managementAttends family meetings as necessaryAssists PCP’s that participate in SNF managementInforms attending and/or ACA medical director of significant changes in medical conditionParticipates in weekly utilization meetings, collaborating with the SNF care team and ACA care managersCoordinates with PCP’s, Hospitalists, ACA Medical Directors and Case ManagersPerforms home visits on selected patientsAddresses /coordinates any legal issues.
Discharge
Develops a discharge plan utilizing input from case management and rehab. Identify barriers to dischargeCreates a detailed discharge summary for each admission on all patients, including medication reconciliation, and sends to the PCP at the time of SNF dischargeEnsures that patients have all appropriate drug and DME prescriptions at dischargeCoordinates visits with the PCP post-dischargeDischarges summary to be sent to the PCP at dischargeUpdates all patients in Care Screen™ before dischargeCoordinates transition from skilled to long term placement.
Long-Term Care
Assists case management in the evaluation of selected long term patientsFollows “new” long term patients every 30 daysAssists the attending physician with management for complex long-term patientsQualifications
EDUCATION AND EXPERIENCE
License to practice as a Registered Nurse and a certificate to practice as a Nurse Practitioner issued by the State Board of Registered Nursing.Geriatrics specialty certification preferredMinimum of three years of clinical nursing experience preferred, including work in a skilled nursing facility.
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GENERAL JOB SUMMARY
An exempt clinical position where the nurse practitioner (NP) is responsible for providing direct patient care. The NP participates as a leader of the skilled nursing facility (SNF) care team. Visits managed care and fee-for-service patients at skilled and long-term levels of care in designated SNFs facilities. Provides appropriate evidence-based geriatric medicine. Coordinates care with hospitalists, primary care physicians and care managers. Makes home visits as directed by the medical staff to meet patient needs and provide continuity of care.
ESSENTIAL JOB FUNCTIONS
Maintains privileges in multiple Nursing Homes as directed by ACAMaintains license and malpractice insuranceConsults supervising attending as neededDocuments patient visits electronically at least 90% of the timeParticipates in documentation and other quality improvement programsAvailable via phone weekdays 8am- 7pm and when on call.Will reviews, approves, and modifies admission ordersCreates a detailed admit note for each admission within 24 hours of patient admission to SNF, including medication reconciliationInitiates/documents Advanced DirectivesDetermines if Health Care Proxy status is correct and invoke if appropriateOn weekends, takes call for admissions and see new patients within 24 hours of admission on a rotating basis with other practitioners in the program.
Daily Visits
Initiates and review orders, including medications, on a daily basisReviews labs, radiology reports, and consults on all patientsTalks to and examines each assigned skilled-level patient on daily rounds Monday through FridayWrites at least one daily progress note for each skilled patientAssess patient’s medical stability daily. Consults/coordinates with specialists as neededAddresses acute mental status changes via non-pharmacologic or pharmacologic measures, consultation or transferCoordinates/assess rehab progress on a daily basisDiscusses concerns with the patient, family, rehab, and case management. Educates patient and family members regarding acute and chronic illness managementAttends family meetings as necessaryAssists PCP’s that participate in SNF managementInforms attending and/or ACA medical director of significant changes in medical conditionParticipates in weekly utilization meetings, collaborating with the SNF care team and ACA care managersCoordinates with PCP’s, Hospitalists, ACA Medical Directors and Case ManagersPerforms home visits on selected patientsAddresses /coordinates any legal issues.
Discharge
Develops a discharge plan utilizing input from case management and rehab. Identify barriers to dischargeCreates a detailed discharge summary for each admission on all patients, including medication reconciliation, and sends to the PCP at the time of SNF dischargeEnsures that patients have all appropriate drug and DME prescriptions at dischargeCoordinates visits with the PCP post-dischargeDischarges summary to be sent to the PCP at dischargeUpdates all patients in Care Screen™ before dischargeCoordinates transition from skilled to long term placement.
Long-Term Care
Assists case management in the evaluation of selected long term patientsFollows “new” long term patients every 30 daysAssists the attending physician with management for complex long-term patientsQualifications
EDUCATION AND EXPERIENCE
License to practice as a Registered Nurse and a certificate to practice as a Nurse Practitioner issued by the State Board of Registered Nursing.Geriatrics specialty certification preferredMinimum of three years of clinical nursing experience preferred, including work in a skilled nursing facility.
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Vitability Health is leading the change in how providers deliver remote care. Our program enables medical teams to provide safe, effective remote care that improves patient outcomes, lowers patient's medical expenses, empowers patients to be fearless, and live longer lives. We are a team of dedicated, mission-driven pros who seek to work with colleagues who inspire us and share our mission and core values
Qualifications
Bilingual a plus
Experience with Medicare patients
Interest in professional leadership growth and development opportunities with a growing organization
Technically savvy and comfortable using tools such as iPads for charting
Interest in operating in a new, exciting clinical program and become an integral player in the development of processes and best practices in caring for RPM patients
Strong verbal and written communication skills
Valid driver’s license with a clean driving record
Ability to lift and carry equipment up to 20 pounds
Comfortable driving to patient’s homes in NYC and providing care
Comfortable seeing patients independently and delivering a positive experience
Full COVID-19 vaccination is a requirement for this position. Medical and religious exemptions may be granted with proper documentation. Heal will adhere to all federal, state, and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance.
Responsibilities
As a care team member you will perform routine primary care nursing tasks, including:Vital signs
Point of care tests (glucometer, etc)
Maintain patient medical records
Documentation consistent with state regulation
As a care team member, you love utilizing motivational communication techniques and strategies, to help drive positive health behavior change and improved patient outcomes
The Practical Nurse (LPN) plays a vital role in educating patients on how to manage their acute or chronic medical conditions, with a goal to maintain health, wellness, and to avoid emergency room utilization and hospitalization
Significantly impact longitudinal patient engagement in RPM program(s)
Provide preventive health and disease management education and coaching
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Vitability Health is leading the change in how providers deliver remote care. Our program enables medical teams to provide safe, effective remote care that improves patient outcomes, lowers patient's medical expenses, empowers patients to be fearless, and live longer lives. We are a team of dedicated, mission-driven pros who seek to work with colleagues who inspire us and share our mission and core values
Qualifications
Bilingual a plus
Experience with Medicare patients
Interest in professional leadership growth and development opportunities with a growing organization
Technically savvy and comfortable using tools such as iPads for charting
Interest in operating in a new, exciting clinical program and become an integral player in the development of processes and best practices in caring for RPM patients
Strong verbal and written communication skills
Valid driver’s license with a clean driving record
Ability to lift and carry equipment up to 20 pounds
Comfortable driving to patient’s homes in NYC and providing care
Comfortable seeing patients independently and delivering a positive experience
Full COVID-19 vaccination is a requirement for this position. Medical and religious exemptions may be granted with proper documentation. Heal will adhere to all federal, state, and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance.
Responsibilities
As a care team member you will perform routine primary care nursing tasks, including:Vital signs
Point of care tests (glucometer, etc)
Maintain patient medical records
Documentation consistent with state regulation
As a care team member, you love utilizing motivational communication techniques and strategies, to help drive positive health behavior change and improved patient outcomes
The Practical Nurse (LPN) plays a vital role in educating patients on how to manage their acute or chronic medical conditions, with a goal to maintain health, wellness, and to avoid emergency room utilization and hospitalization
Significantly impact longitudinal patient engagement in RPM program(s)
Provide preventive health and disease management education and coaching
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We are seeking an experienced Director of Nursing (RN) to lead and oversee all clinical operations for our growing hospice organization. The ideal candidate is a strong clinical leader with hands-on hospice experience, a deep understanding of Medicare Conditions of Participation, and the ability to build, mentor, and manage an interdisciplinary team.
Hospice experience is required. This is not an entry-level leadership role.
Responsibilities:
Provide clinical leadership and oversight of all hospice nursing services
Ensure compliance with federal and state hospice regulations and Medicare CoPs
Supervise and support RNs, LPNs, aides, and clinical staff
Oversee care plans and interdisciplinary team meetings
Maintain quality assurance and performance improvement programs
Ensure accurate and timely clinical documentation
Participate in survey readiness and regulatory audits
Collaborate with the Administrator and Medical Director to ensure high-quality patient care
Assist with hiring, onboarding, and clinical training
Qualifications:
Active Registered Nurse (RN) license in NJ
Minimum 2–3 years hospice experience required
Prior hospice leadership or supervisory experience strongly preferred
Strong knowledge of hospice regulations, compliance, and documentation standards
Experience with EMR systems
Excellent communication and team leadership skills
What We Offer:
Competitive salary
Supportive leadership environment
Opportunity to help build and grow a high-quality hospice program
Benefits package
If you are a passionate hospice RN leader who values patient-centered care and strong clinical standards, we would love to speak with you.
Read LessWe are seeking an experienced Director of Nursing (RN) to lead and oversee all clinical operations for our growing hospice organization. The ideal candidate is a strong clinical leader with hands-on hospice experience, a deep understanding of Medicare Conditions of Participation, and the ability to build, mentor, and manage an interdisciplinary team.
Hospice experience is required. This is not an entry-level leadership role.
Responsibilities:
Provide clinical leadership and oversight of all hospice nursing services
Ensure compliance with federal and state hospice regulations and Medicare CoPs
Supervise and support RNs, LPNs, aides, and clinical staff
Oversee care plans and interdisciplinary team meetings
Maintain quality assurance and performance improvement programs
Ensure accurate and timely clinical documentation
Participate in survey readiness and regulatory audits
Collaborate with the Administrator and Medical Director to ensure high-quality patient care
Assist with hiring, onboarding, and clinical training
Qualifications:
Active Registered Nurse (RN) license in NJ
Minimum 2–3 years hospice experience required
Prior hospice leadership or supervisory experience strongly preferred
Strong knowledge of hospice regulations, compliance, and documentation standards
Experience with EMR systems
Excellent communication and team leadership skills
What We Offer:
Competitive salary
Supportive leadership environment
Opportunity to help build and grow a high-quality hospice program
Benefits package
If you are a passionate hospice RN leader who values patient-centered care and strong clinical standards, we would love to speak with you.
Read LessVitability Health is leading the change in how providers deliver remote care. Our next-generation Remote Patient Monitoring (RPM) program enables medical teams to provide safe, effective remote care that improves patient outcomes, lowers patient's medical expenses, empowers patients to be fearless, and live longer lives. We are a team of dedicated, mission-driven pros who seek to work with colleagues who inspire us and share our mission and core values
Qualifications
Bilingual russian speaking
Experience with Medicare patients
Interest in professional leadership growth and development opportunities with a growing organization
Technically savvy and comfortable using tools such as iPads for charting
Interest in operating in a new, exciting clinical program and become an integral player in the development of processes and best practices in caring for RPM patients
Strong verbal and written communication skills
Valid driver’s license with a clean driving record
Ability to lift and carry equipment up to 20 pounds
Comfortable driving to patient’s homes in NYC and providing care
Comfortable seeing patients independently and delivering a positive experience
Full COVID-19 vaccination is a requirement for this position. Medical and religious exemptions may be granted with proper documentation. Heal will adhere to all federal, state, and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance.
Responsibilities
As a care team member you will perform routine primary care nursing tasks, including:Vital signs
Point of care tests (glucometer, etc)
Maintain patient medical records
Documentation consistent with state regulation
As a care team member, you love utilizing motivational communication techniques and strategies, to help drive positive health behavior change and improved patient outcomes
The MA/LPN/RN plays a vital role in educating patients on how to manage their acute or chronic medical conditions, with a goal to maintain health, wellness, and to avoid emergency room utilization and hospitalization
Significantly impact longitudinal patient engagement in RPM program(s)
Provide preventive health and disease management education and coaching
Read Less
Vitability Health is leading the change in how providers deliver remote care. Our next-generation Remote Patient Monitoring (RPM) program enables medical teams to provide safe, effective remote care that improves patient outcomes, lowers patient's medical expenses, empowers patients to be fearless, and live longer lives. We are a team of dedicated, mission-driven pros who seek to work with colleagues who inspire us and share our mission and core values
Qualifications
Bilingual russian speaking
Experience with Medicare patients
Interest in professional leadership growth and development opportunities with a growing organization
Technically savvy and comfortable using tools such as iPads for charting
Interest in operating in a new, exciting clinical program and become an integral player in the development of processes and best practices in caring for RPM patients
Strong verbal and written communication skills
Valid driver’s license with a clean driving record
Ability to lift and carry equipment up to 20 pounds
Comfortable driving to patient’s homes in NYC and providing care
Comfortable seeing patients independently and delivering a positive experience
Full COVID-19 vaccination is a requirement for this position. Medical and religious exemptions may be granted with proper documentation. Heal will adhere to all federal, state, and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance.
Responsibilities
As a care team member you will perform routine primary care nursing tasks, including:Vital signs
Point of care tests (glucometer, etc)
Maintain patient medical records
Documentation consistent with state regulation
As a care team member, you love utilizing motivational communication techniques and strategies, to help drive positive health behavior change and improved patient outcomes
The MA/LPN/RN plays a vital role in educating patients on how to manage their acute or chronic medical conditions, with a goal to maintain health, wellness, and to avoid emergency room utilization and hospitalization
Significantly impact longitudinal patient engagement in RPM program(s)
Provide preventive health and disease management education and coaching
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