Nurse Care Manager

Upward Health•Monroe, LA

40d•Hybrid

About The Position

The Nurse Care Manager is a hybrid role (field work/work-from-home) 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 personalized care plans
Collaborate with a multidisciplinary Care Team
Focus on chronic care management and care transitions
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
Ensure patients understand and follow their care plans
Work effectively with the multidisciplinary Care Team Pod
Actively reach out to patients and caregivers within 48 hours of discharge
Provide clear, compassionate education to patients and families
Empower patients to manage their health
Coordinate care across multiple providers, institutions, and services
Effectively manage patient caseloads
Balance multiple tasks while adhering to deadlines and care plans
Identify potential gaps in care
Resolve issues through collaboration with providers
Work to optimize patient outcomes
Maintain patient confidentiality and follow HIPAA regulations
Demonstrate respect for diversity
Ensure culturally sensitive care
Develop and implement care plans
Deliver complex medical information clearly
Create personalized care plans that address physical, behavioral, and social health needs
Use electronic health records (EHR) and care management systems
Document, track, and coordinate patient care
Achieve optimal clinical and financial outcomes
Work independently in a field-based setting
Collaborate effectively with a multidisciplinary team
Use clinical judgment to assess, analyze, and evaluate patient progress
Adapt care plans as needed
Manage multiple patient cases simultaneously
Prioritize tasks to meet deadlines and ensure comprehensive care
Motivate patients to follow care plans and improve self-care skills