RN Nurse Care Manager
About The Position
HarmonyCares is a national value-based provider of in-home primary care for people with complex healthcare needs. The RN Nurse Care Manager is an integral member of the care team, managing a caseload of high-risk patients and addressing their care needs and barriers. The role includes transitional and chronic care management, disease and medication education, and development and management of patient care plans. The Nurse Care Manager also serves as co-chair of the pod alongside the pod leader, focusing on prioritizing patient needs and improving outcomes. The Nurse Care Manager coordinates services across the care continuum, works with the care team to identify and close care gaps, and supports patients and caregivers through education and care transitions. This position includes telephone nursing assessments, medical-record review, patient prioritization, documentation, and communication with patients, caregivers, providers, and other resources.
Requirements
- Active Registered Nurse license.
- At least 2 years of care management experience in community, health plan, or hospital systems.
- Strong clinical skills and proactive thinking.
- Effective communication skills and ability to conduct extensive telephone assessments.
- Knowledge of Medicare regulations and home care and hospice standards.
- Experience with small-group presentations and teaching or training.
- Excellent interpersonal, written, and oral communication skills.
- Working knowledge of computer programs including email, Word, Excel, and PowerPoint.
- Ability to manage time effectively and complete duties and documentation in a timely manner.
Nice To Haves
- Bachelor of Science in Nursing or a related field.
- May be required to obtain multi-state licensing.
- Strong knowledge of population health, quality measures, care gap closure, and value-based care models.
Responsibilities
- Coordinate care services with the pod leader to provide patients with comprehensive services tailored to their needs.
- Collaborate with the care team to develop and manage personalized care plans, address care gaps, and connect patients with resources.
- Coordinate care transitions throughout the continuum and help prevent avoidable hospital admissions.
- Coordinate and facilitate High Risk Huddles and ensure follow-up actions are completed.
- Prioritize patients according to the severity and urgency of their conditions.
- Review medical records to identify care gaps and coordinate with the care team to address them.
- Regularly update patient care plans.
- Conduct thorough nursing assessments of patients by telephone to maximize or improve health outcomes.
- Educate patients and caregivers about diseases, medications, health maintenance, and disease prevention.
- Communicate effectively with patients, caregivers, providers, and care-team members using clinical skills and critical thinking.
- Document interactions, assessments, and updates in patient medical records according to processes and guidelines.
- Serve as a liaison among patients, providers, and resources to support seamless care delivery.
- Communicate patient status and care plans during transitions such as home to hospital, hospital to post-acute care, and back home.
Benefits
- Quarterly bonuses
- Health insurance
- Dental insurance
- Vision insurance
- Disability insurance
- Life insurance
- 401(k) retirement plan with company match
- Tuition reimbursement
- Professional license and certification reimbursement
- Paid time off
- Paid holidays
- Paid volunteer time
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
