RN Care Manager

Participation in a rotating on-call schedule

Ability to visit patients in their homes as needed (though most work will be performed on-site)

On‑call and home visits are mandatory for this role.
On‑call rotation applies to all NPs and RNs. It is primarily triage‑based for any after‑hours emergencies.
They will split their time between the clinic and the field, with the majority of their responsibilities involving home visits.

Key responsibilities include:

Completing full patient assessments

Creating individualized health plans

Providing treatment focused on chronic conditions common in geriatric populations

Chronic conditions are long-term health issues requiring ongoing management, such as diabetes, hypertension, pulmonary disease, kidney failure, multiple sclerosis, and Parkinson’s disease.

The overall goal is to keep patients as independent as possible, ensure they have all the resources they need, and reduce rehospitalizations by keeping them healthy and safe in their homes.