Care Coordinator for Chronic Care Patients

4 weeks ago


Viola, Delaware, United States CAI Full time
Job Summary:
Care Coordinators at CAI play a vital role in ensuring the health and well-being of patients with chronic care needs. As a Registered Nurse Case Manager, you will be responsible for providing community-based care coordination, assessing and managing patient healthcare needs, and collaborating with healthcare teams to deliver optimal care.

About the Role:
This is a full-time 3-month contract-to-hire position requiring a licensed Registered Nurse (RN) with experience in case management and discharge planning. The ideal candidate will have a strong understanding of geriatric special needs, behavioral health, and home health. You will work closely with patients, their families, and healthcare providers to develop and implement personalized care plans that address physical, behavioral, and social needs.

Responsibilities:
- Travel to patients' homes, nursing facilities, and other community settings to conduct face-to-face assessments and provide education on healthcare needs, benefits, resources, and services
- Assess, plan, coordinate, implement, and evaluate care for eligible patients with chronic and complex healthcare needs
- Coordinate care across the continuum of services, including referrals to disease/chronic condition management, behavioral health, and complex case management programs
- Facilitate transitions between care settings, such as hospital to home or nursing facility to community setting
- Educate patients and caregivers on health care needs, available benefits, resources, and services, including options for long-term care delivery

Requirements:
- Current RN licensure in Delaware with 5+ years of case management and discharge planning experience
- Experience working with geriatric special needs, behavioral health, and home health populations
- Strong understanding of cultural competency and ability to communicate effectively with diverse patient populations
- Proficiency in PC-based word processing and database documentation (Word, Excel, Internet, Outlook)
- Reliable transportation daily to travel within assigned territory

What We Offer:
- Competitive salary: $85,000 per year
- Hybrid work arrangement allowing flexibility to work from home and office
- Opportunity to make a meaningful impact on patients' lives by providing exceptional care coordination and support

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