Do you want to make a difference in healthcare?

Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community.  Our medical group provides home-based medical care to chronically ill patients, many of whom are frail, elderly and ill-equipped to navigate our overwhelming healthcare system.

Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients at no incremental financial cost to them. We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.

Our model is finding success throughout the country; we are now the nation’s largest risk-based, in-home medical group, with operations in six markets and four states across the country.

At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health and other employed team members.

The Nurse Care Manager (CM) Manager is responsible, as part of the care team, for the overall patient Care Management process. The CM provides oversight, guidance and support for the member care plan as developed through clinician, CM and allied clinical support evaluation and physical risk assessment.

The CM uses nursing assessment and evaluation skills to help guide treatment and care decisions of the team and also identifies services and vendors for needed care while navigating patient benefit plans. The CM works collaboratively with a multidisciplinary team of PCP, specialists, Behavioral Health clinicians, midlevel practitioners, pharmacist, nutritionist and Social Worker and the member, family and/or caregiver as they provide supportive care to enrolled members.

The CM ensures that medical services are managed in the most effective and appropriate health care setting according to the member’s medical condition. The CM is responsible for developing and implementing a plan of care appropriate to the member’s clinical condition and psycho/social needs to maximize his/her level of functioning and establishing and maintaining communications with the responsible party of the member.

• Acts as an advocate for the member in all activities including nursing assessments, care coordination, care plan development, and communication.
• This position is accountable for identifying and developing innovative actions to meet the needs of the member from both the health care and psychosocial / socioeconomic dimensions of care as well as taking action for provision of services to meet those needs.
• The CM utilizes nursing assessment skills and decision making authority to make recommendation and direct member care to meet the needs of the member and support the care recommendations of the multidisciplinary care team, the member, family and caregiver.
• Complete an initial member assessment on all new enrolled members, including a medical record review where available
• Documentation of current advance care directive status and ongoing efforts to reconcile member/caregiver misaligned goals with current clinical status
• Perform ongoing assessments commensurate with member risk level and/or identified need
• Development of a plan of care to establish a collaborative approach to member needs across clinicians and care delivery
• Initiate and maintain ongoing communications with clinicians involved in member care, especially PCP
• Meet with families/responsible parties for collaboration on member plan of care and discussion of member/family/responsible party contribution to the ongoing management of member condition
• Coordinate care across the continuum of care delivery model as the point of contact for member/caregiver and clinicians
• Act as liaison between providers, nursing facilities, hospitals and program staff, including making recommendations about care alternatives or equipment that will aide in the safety of the member while promoting optimal clinical outcomes
• Monitor member progress to plan of care goals with emphasis on member care need during transitions and changes in member level of care needs
• Monitor member during admissions to both acute and skilled level of care to support member needs, establish as the point of contact to clinicians and member/responsible party/families to ensure consistent and ongoing communication between all involved parties
• Provide nursing/assisted living facility and provider training on program philosophy and approach to member care
• Main educator for members and/or families/responsible parties on disease processes and ways to manage disease progression as independently as possible
• Reviews medical information collected including medical records and/or performs additional assessment to facilitate medical necessity determinations regarding service requests as established with in the identified program guidelines and the state established nurse scope of practice
• Serve as a resource to the entire care delivery team
• Identification and reporting of any quality of care issues
• Maintain HIPAA compliance as it relates to member care
• Attend departmental meetings
• Completes other duties as assigned

• RN License, BSN preferred
• 2-3 years of clinical practice in a hospital, clinic, home care, or nursing home setting
• 1-2 years of utilization management experience a must
• Case management experience desired
• Disease management experience useful
• Physician office experience helpful

Certificates, Licenses, Registrations:

• Current state RN license