RN Care Manager - Home Care FT (RI) (CRC) in Rhode Island at Prospect Medical Systems

Date Posted: 2/8/2021

Job Snapshot

Job Description

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Current employees can apply directly through the Internal Careers Center online for Prospect Medical job openings in California. For a streamlined application process, all you need is your four-digit employee ID number and a digital copy of your résumé handy before you apply.

RN - Care at Home (CAH-RN) - (CRC - RI)

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Care at Home-Registered Nurse (CAH-RN) effectively at their home by visiting patients at home and telephonically to support complex and chronic care needs by 1) develop a trusting relationship b) clinically assessing patients c) empathizing and identifying the challenges patients and families face, d) help patients and families in prioritizing and resolving the challenges in recovery by ensuring PCP appointments,  assessing home situation, support available from family & caregivers, teaching patients and families about key disease conditions as relevant, ensuring education to help with medication adherence to ensure steady recovery and prevent unnecessary hospital admissions. The CAH-RN will work in collaboration with the patients’ family members, caregivers and PCP to solicit and ensure additional help required by patients as they move through their health continuum. In addition, CAH-RN will prioritize patients’ medical, environmental and psychosocial needs with the goal of optimizing medical Care at Home- where every one of our patients want to be!

Job Responsibilities/Duties

  • Engages and enrolls patients into Care at Home while setting the foundation for a longitudinal medical Care at Home team approach
  • Prioritize patients to visit based on their clinical complexity (which indirectly reflects their needs), their discharge location (SNFs vs Hospitals), readmission risk stratification
  • Performs an in home visit to assigned patients within 72 hours of discharge to home
  • CAH-RN will review the discharge plan from the hospital, interview patients and their caregivers, assess their home to identify potential challenges that will result in patient returning to hospital, prioritize these challenges for resolution and be relentless in solving patient challenges
  • Solving some of these challenges would require patient education to identify clinical decline early and engendering patient trust so that patients and families call Care at Home team early if they are having challenges, helping patients in resolving conflicting information about medicines and procuring rescue packs.
  • For select patients, it would require thoughtful communication with patients and families while bringing other experienced clinical colleagues e.g. Palliative care nurses, Pharmacists to help patients, Social Workers and Community Health Workers
  • Assist in closing HEDIS care gaps during home visit through Point of Care testing
  • It is estimated 50-60% of patient contact would be telephonic while other 40-50% would require face to face interaction with patients and families.
  • Manage patient panel of 150 patients. Meets assigned/expected patient home visits/contacts daily to assess and coordinate clinical care. In addition, CAH-RN coordinates care with PCP, Medical Director, CAH-Nurse Practitioner, Care Coordinator and participates in weekly Interdisciplinary Rounds to solicit help from others and share expertise with others.


Minimum Education:  RN unrestricted active license for State of RI.

Minimum Experience: Two (2) years’ experience in care management preferably in an acute care setting or home health care. Demonstrated ability in developing trusting relationships. Comfortable working in patient’s homes, respectful of patient autonomy and able to persuade patients and families. Strong clinical background to assess patients, educating families and patients. Ability to develop a plan to empower patients to gain disease state self-management skills. Experience with Microsoft Office Word and Electronic Health Records. Valid unrestricted Driver’s license. Willingness to travel throughout State of RI but mostly focused around Providence. Participate in on-call rotation. Ability to manage, prioritize and handle action items, care of 150-180 patients. Able to work independently and comfortable in making independent decisions while soliciting input from other colleagues, as needed. Ability to multi-task. Excellent written and verbal communication skills. Familiar/conversant with computers (emails, EMR, calendar, phone) to work autonomously.  Maintain courteous professional attitude when working with internal and external customers. Maintains member confidence and protects operations by keeping claim information confidential in compliance with HIPAA requirements.

Req. Certification/Licensure:  RN unrestricted active license for State of RI.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance

How to Apply

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm

Keywords: RN, HomeCare, EMR, Travel RN, HIPPA, Acute Care, Clinical, PCP, Chronic Care, Patient Care.



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