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 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.

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.

Join Landmark to be part of a growing company full of purpose-driven, action-oriented, and compassionate team members working to dramatically transform healthcare for our communities.

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 by providing care coordination, health education, guidance and support for medical and psychosocial complex chronic conditions. 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.

Primary Responsibilities:

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  Acts as an advocate for the patient
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  Engages and collaborates with patient/caregiver and providers to develop an individualized Care Plan that addresses disease management, health promotion, and patient-centered goals
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  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
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  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 encourage proper medical testing, so patient can remain as independent as possible
  
• Completes initial and ongoing patient assessment, using information gathered from patient/caregiver/family, providers, Landmark EMR, and available medical records
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  Ability to manage and coordinate care and services within an Interdisciplinary Team
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  Manage incoming clinical calls to ensure patients’ medical concerns are addressed by the care team in a timely manner
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  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
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  Actively participates in Landmark meetings and education sessions
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  Acts as liaison between providers, nursing facilities, hospitals and program staff, including making recommendations about care alternatives
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  Facilitates/coordinates admission to a recommended level of care on a temporary or permanent basis
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  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
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  At times, the NCM may visit a patient in their home for education or assessment, Market/State dependent
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  Maintains HIPAA compliance at all times

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

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  RN License in the State(s) where you will practice - RN License must be current, active, unrestricted and unencumbered
  
• Proficient in patient-centered Care Plan creation and active management
  
• 3+ years of clinical practice in a hospital, home care, hospice, clinic, or nursing home setting
  
• Electronic Medical Record documentation experience
  
• Computer skills: internet navigation, Microsoft Office - Outlook, Word and Excel
  
• Access to reliable transportation required; if you are driving a vehicle, you must comply with all the terms of the Landmark Motor Vehicle Safety policy

Preferred Qualifications:

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  BSN
  
• Case Management experience
  
• 1+ years of Utilization Management experience
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  Disease state management experience with ability to educate patients on health and wellness
  
• Population Health management experience
  
• Ability to manage a patient caseload using data and reports highly
  
• Ability to complete all work independently and within designated timeframes
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  Advanced interpersonal and telephonic communication skills
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  Solid organizational skills
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  Adaptable, flexible, and able to maintain a positive attitude during change in process, practice or policy

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

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Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

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