Nurse Care Manager

Upward Health•San Francisco, CA

1d•Hybrid

About The Position

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. Our clinical team treats physical, behavioral, and social health needs when and where a patient needs help. Everyone on our team from our doctors, nurses, and Care Specialists to our HR, Technology, and Business Services staff are driven by a desire to improve the lives of our patients. We are able to treat a wide range of needs – everything from addressing poorly controlled blood sugar to combatting anxiety to accessing medically tailored meals – because we know that health requires care for the whole person. It’s no wonder 98% of patients report being fully satisfied with Upward Health! The Nurse Care Manager is a field-based 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)
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

Case management certification is a plus but not required

Responsibilities

Care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions.
Collaborate with a multidisciplinary Care Team to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention.
Focus on chronic care management and care transitions, particularly for patients discharged from inpatient settings.
Conduct both in-person and telephonic outreach.
Perform medication reconciliation.
Ensure continuity of care across the healthcare ecosystem.
Act as an advocate for patients.
Ensure the 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 ensure 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 manage patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.
Identify potential gaps in care, resolve issues through collaboration with providers, and work to optimize patient outcomes.
Maintain patient confidentiality and follow HIPAA regulations to ensure privacy in all interactions.
Demonstrate respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.
Develop and implement care plans using strong knowledge of chronic disease management, care transitions, and evidence-based practices.
Deliver complex medical information clearly to patients, caregivers, and interdisciplinary teams.
Create personalized care plans that address physical, behavioral, and social health needs.
Use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.
Achieve optimal clinical and financial outcomes for patients through effective care coordination and management.
Work independently in a remote environment while also collaborating effectively with a multidisciplinary team.
Use clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.
Manage multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.
Motivate patients to follow care plans and improve self-care skills through regular communication and support.