Landmark Health

Nurse Care Manager, Palliative

Job Locations US-NY-Latham
Posted Date 3 weeks ago(7/14/2020 4:03 PM)
Clinical Delivery Field
Regular Full-Time
Job ID


The Nurse Care Manager (NCM), is an integral part of the Interdisciplinary care team (IDT), and is responsible for the overall care management process for high acuity engaged Landmark patients . The NCM has oversight for developing, managing, and coordinating patients’ plan of care to include medical and psychosocial needs and patient-centered goals. The NCM works with patients/caregivers to maintain and improve health status and quality of life by providing care coordination, health education, guidance and support for medical and psychosocial complex chronic conditions, including serious illness with limited prognosis. The NCM also provides support with advancing goals of care discussions, managing symptoms, and facilitating hospice transitions. Professionals in this role elicit input from the IDT based on initial and ongoing comprehensive assessments of the patient.

The NCM uses nursing assessment, evaluation skills, data and reports to guide care planning decisions for the patient. They are skilled at navigating the patients’ health plan benefits to identify providers, resources and vendors that provide required care and services. The NCM works collaboratively with the IDT to provide appropriate, effective, high quality, and cost-effective care to engaged patients in their current residence. If a patient requires care outside their residence, the NCM collaborates with community-based service providers to ensure coordinated care during critical times of transition between health care settings and home.

In addition to the NCM, the Landmark IDT consists of the Regional Medical Director, Pod Leaders, mid-level practitioners, Health Services Director (HSD), clinical supervisors, behavioral health clinicians, social workers, pharmacists, dietitian/nutritionist, ambassadors, care coordinators, the patient and/or caregiver and family.


• Acts as an advocate for the patient
• Engages and collaborates with patient/caregiver and providers to develop an individualized Care Plan that addresses disease management, symptom management, quality of life promotion, and patient-centered goals
• Monitors patient progress against Care Plan goals with an emphasis on patient care needs during times of transition in care setting and changes in health status
• In a Delegated Case Management market, understands and adheres to regulatory timeframes and standards required by National Committee for Quality Assurance (NCQA )
• Provides disease management, health promotion and prevention education to patients/caregivers and/or family members to manage disease progression and to promote care plans that focus on relief from the symptoms and stress of one or more serious illnesses to improve quality of life for both the patient and the family
• Completes initial and ongoing patient assessment, using information gathered from patient/caregiver/family, providers, Landmark EMR, and available medical records
• Ability to manage and coordinate care and services within an Interdisciplinary Team
• Manage incoming clinical calls to ensure patients’ medical concerns are addressed by the care team in a timely manner
• Comfortable having and documenting advance directive conversations with patient/caregiver and/or family, and collaborate to reconcile patient/caregiver goals with the current clinical status
• Coordinates care needs across the continuum of care and is the point of contact for patient/caregiver and clinicians
• Leads daily IDT Huddle
• Actively participates in Landmark meetings and education sessions
• Acts as liaison between providers, nursing facilities, hospitals and program staff, including making recommendations about care alternatives
• Facilitates/coordinates admission to a recommended level of care on a temporary or permanent basis
• Promotes patient safety. Reviews or initiates a home safety, functional assessment, and/or falls risk assessment with home-based providers to determine need for adaptive equipment. Assists with acquisition of assistive equipment, as recommended
• Monitors patient during admissions and provides nursing/assisted living facility and provider training on Landmark program philosophy and approach to patient care
• Identifies and reports any potential quality-of-care issues to Clinical Supervisor/HSD, so a plan of improvement can be developed and implemented, as needed
• At times, the NCM may visit a patient in their home for education or assessment, Market/State dependent
• Maintains HIPAA compliance at all times


• Must hold RN License in the State(s) where you will practice. RN License must be current, active, unrestricted and unencumbered, BSN preferred
• Case Management experience preferred
• Proficient in patient-centered Care Plan creation and active management required
• 3+ years of clinical practice in a hospital, home care, hospice, clinic, or nursing home setting required
• 1+ years of Hospice and/or palliative care experience desired
• Disease state management experience with strong ability to educate patients and caregivers on improved symptom management and quality of life.
• Population Health management experience desired
• Ability to manage a patient caseload using data and reports highly desired
• Advanced interpersonal and telephonic communication skills
• Strong organizational skills
• Ability to complete all work independently and within designated timeframes
• Adaptable, flexible, and able to maintain a positive attitude during change in process, practice or policy
• Electronic Medical Record documentation experience required
• Computer skills: internet navigation, Microsoft Office – Outlook, Word and Excel required
• Current Driver License


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