Nurse Care Manager

Upward Health•Lake Charles, LA

40d•Hybrid

About The Position

The Nurse Care Manager is a hybrid (field work/work-from-home) role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem. The Nurse Care Manager acts as an advocate for patients and ensures the integration of services across providers, hospitals, and outpatient services.

Requirements

Registered nursing license (unrestricted)
Minimum of three years of clinical nursing experience
Expertise in care management and coordination across healthcare providers
Strong communication skills for patient and caregiver education
Ability to conduct both in-home and telephonic assessments, care plans, and medication reconciliations
Experience with EHR systems and real-time documentation
Ability to work independently and manage multiple patient cases
Critical thinking and decision-making skills in developing care plans
Proficient in using digital tools for care coordination and communication
A valid driver’s license and auto liability insurance
Reliable transportation and the ability to travel within assigned territory or as needed

Nice To Haves

Preferred experience in care management, case management, or transitional care settings
Experience in acute care environments such as ICU, Med-Surg, or ER is also highly valued
Case management certification is preferred but not required

Responsibilities

Care coordination of high-risk patients
Develop comprehensive care plans addressing chronic conditions
Collaborate with a multidisciplinary Care Team
Ensure optimal health outcomes through personalized care plans, self-management, and disease prevention
Focus on chronic care management and care transitions, especially for patients discharged from inpatient settings
Conduct in-person and telephonic outreach
Perform medication reconciliation
Ensure continuity of care across the healthcare ecosystem
Act as an advocate for patients
Ensure integration of services across providers, hospitals, and outpatient services
Develop strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.
Work effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.
Actively reach out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.
Provide clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.
Ensure that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.
Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.
Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.
Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.
Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.
Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.
Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.
Proficient in creating personalized care plans that address physical, behavioral, and social health needs.
Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.
Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.
Able to work independently in a field-based setting while also collaborating effectively with a multidisciplinary team.
Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.
Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.
Motivates patients to follow care plans and improve self-care skills through regular communication and support.