Care Manager - RN

Develop and adapt individualized care plans in conjunction with physicians, performing frequent daily in-home visits to execute these strategies. Serve as the primary point of contact for plan members, answering health questions and conducting post-op and hospital discharge assessments to support vulnerable transitions. Monitor biometric data, inventory medications, and coordinate with pharmacists and dialysis providers to ensure seamless care transitions. Deliver education on CKD, ESRD, and dialysis while encouraging treatment adherence through frequent contact. Review member updates in the care management platform and communicate recommendations during weekly internal case rounds. This role focuses on creating and administering care plans to prevent avoidable hospitalizations and readmissions, engaging positively with social workers to address behavioral needs.