Esse Health

Manager

• Understands and implements the core objectives of the Esse RN Care Management program.
• Conducts timely and comprehensive face-to-face and follow-up visits with patients across various community settings.
• Acts as a liaison for the Esse Health Primary Care Physician, coordinating communication and care planning among patients, families, and healthcare providers.
• Determines the need for follow-up care based on patient acuity, therapy progress, medical conditions, and social service interventions.
• Develops and manages individualized discharge plans with input from the patient, family, PCP, and interdisciplinary care teams.
• Reviews facility notes and provider documentation to reassess discharge and care plans.
• Identifies potential barriers in the home and community environment that may impact recovery or quality of life.
• Applies evidence-based medicine guidelines and assessment tools to ensure high-quality care.
• Coordinates home care services including skilled nursing, therapy, durable medical equipment (DME), and community-based resources.
• Partners with PCP offices to schedule timely post-discharge appointments and ensure continuity of care.
• Completes documentation accurately, thoroughly, and on time within the designated electronic medical records (EMR) system.

Care Manager – RN