Provides in-home nursing case management for patients in an Advanced Care at Home program.
Key responsibilities
- Assess patients’ clinical status and care needs.
- Coordinate care plans across providers and relevant community resources.
- Monitor treatment response and patient progress.
- Educate patients and families on care plans, self-management, and health goals.
- Communicate clinical changes and updates to the care team and ordering providers.
- Document assessments, interventions, and outcomes in the electronic health record.
Required qualifications & skills
- Strong clinical judgment and ability to manage patient care in the home setting.
- Excellent communication skills for coordinating care and educating patients/families.
- Detail-oriented documentation and proficiency with electronic health record systems.
- Ability to assess, monitor, and respond to changes in patient condition.