Targeted Care Navigation, Local Nurse Care Manager

About the role

Targeted Care Navigation Local Nurse Care Managers provide comprehensive, in‑home care management services to high‑risk patients. The role focuses on preventing hospital readmissions, improving health outcomes, and ensuring patients receive the support and resources they need to manage their conditions effectively. The Nurse Care Manager works closely with patients, families, and other healthcare providers to develop and implement personalized care plans that address each patient’s unique needs, and collaborates with a Community Health Worker and an Included Health Virtual PCP.

Responsibilities

• Conduct in‑person visits to assess patient health status, educational, and psychosocial needs at homes, hospitals, or medical appointments.
• Generate a comprehensive individualized plan of care and targeted interventions with patients and the multidisciplinary care team.
• Provide education and support to patients and families on managing chronic conditions, medications, and lifestyle changes.
• Identify and address barriers to care, including social determinants of health, and connect patients with community resources with support from a remote Licensed Social Worker and Local Community Health Worker.
• Collaborate with patients, the remote Included Health team, community physicians, family members, and other health‑care team members to ensure coordinated care.
• Continuously monitor patient response to the plan of care and revise the care plan as indicated.
• Implement systems of care that facilitate close monitoring of high‑risk patients to prevent or intervene early during acute exacerbations.
• Maintain required documentation for all care‑management activities.
• Participate in case conferences and care‑coordination meetings to ensure a holistic approach to patient care.
• Participate in member engagement initiatives, including outreach to local provider and hospital groups.
• Stay current with best practices and evidence‑based guidelines in chronic disease management and care coordination.
• Provide compassionate, longitudinal follow‑up care, building supportive relationships.
• Assist throughout acute health‑care episodes (hospitalizations, rehabilitation stays) by providing coordinated case management to support the member and family.

Required Qualifications

• Current Bachelor of Science in Nursing (BSN).
• Active RN license in good standing in AZ, TX, or IL.
• BLS certification.
• Current driver’s license, reliable transportation, car insurance, acceptable driving record; willingness to travel up to ~50 miles for in‑person visits.
• 2+ years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical‑surgical setting within the past five years.
• Strong clinical assessment, physical exam, and critical thinking skills.
• Broad knowledge of chronic conditions, evidence‑based guidelines, prevention, wellness, health risk assessment, and patient education.
• Excellent verbal and written communication; ability to write medical information in patient‑centric language.
• Ability to work independently with strong internal drive and to communicate challenges to leadership.
• Excellent interpersonal and facilitation skills.
• Excellent time‑management and adaptability to changing priorities.
• High empathy and ability to understand cultural and socioeconomic issues; strong rapport building with diverse patients and families.

Valued Qualifications

• Current CCM certification (where not required).
• 5+ years of nursing experience.
• Comfort with technology and experience working remotely or with innovative care teams.
• Experience working with patients in their homes.
• Bilingual in Spanish and English.
• Ability to maintain a flexible schedule; position may require weekend work.

Physical / Cognitive Requirements

• Driving to members’ homes up to 5 days per week over a wide geographic area.
• Prompt and regular attendance at assigned work location.
• Ability to remain seated in a stationary position for prolonged periods.
• Eye‑hand coordination and manual dexterity sufficient to operate keyboard, computer, and other office equipment.
• No heavy lifting expected; occasional exertion of about 20 lb (e.g., lifting a laptop) may be required.
• Ability to interact appropriately with leadership, employees, and members.

Compensation

The United States new‑hire base salary target ranges for this full‑time position are: Zone A: $74,810 – $104,730 plus equity and benefits. Final salary will consider education, training, skill set, experience, certifications, licensure, business needs, internal equity, and geographic market data.

Benefits

• Remote‑first culture.
• 401(k) savings plan through Fidelity.
• Comprehensive medical, vision, and dental coverage (multiple plan options, including disability insurance).
• Full suite of Included Health telemedicine and health‑care navigation products at no cost for employees and dependents.
• Generous Paid Time Off (PTO) and Discretionary Time Off (DTO).
• 12 weeks of 100 % paid parental leave.
• Family Building Benefit with fertility coverage and up to $25,000 for surrogacy & adoption assistance.
• Compassionate Leave (paid leave for failed pregnancy, surrogacy, adoption, or fertility treatment).
• 11 paid holidays plus one floating paid holiday.
• Work‑From‑Home reimbursement to support home office setup.
• 24 hours of paid volunteer time off (VTO) per year.

About Included Health

Included Health is a new kind of healthcare company delivering integrated virtual care and navigation. Its mission is to raise the standard of healthcare for everyone by breaking down barriers and providing high‑quality care for every person in every community—whether the need is acute or chronic, behavioral