AIMS- REMOTE RN CARE MANAGER

Job Description

The Longitudinal Care Manager provides ongoing care coordination and management for patients over time, ensuring continuity of care, optimal health outcomes, and appropriate utilization of services. This role supports patients across the continuum of care following initial assessments through regular monitoring, plan adjustments, and collaboration with multidisciplinary teams.

Key Responsibilities :

• Manage a caseload of patients longitudinally, tracking health status, progress, and care needs.
• Update and adjust individualized care plans based on patient condition, clinical goals, and evolving needs.
• Coordinate with physicians, specialists, community resources, and other care providers to ensure comprehensive care delivery.
• Conduct regular patient outreach via phone or telehealth to monitor health, provide education, and reinforce care plans.
• Identify barriers to care and implement strategies to address social, behavioral, or medical needs.
• Document all patient interactions, care plan updates, and progress notes accurately in the electronic health record (EHR).
• Facilitate smooth transitions between stages of care (initial, palliative, hospice) when appropriate.
• Serve as a resource and advocate for patients and their families.

Qualifications :

Preferred :

Meet Your Recruiter

Stacey Behar