RN Nurse Care Manager

HarmonyCares•Roanoke, VA

About The Position

HarmonyCares is a national value-based provider of in-home primary care for people with complex healthcare needs. The Nurse Care Manager is an integral member of the care team and manages a caseload of high-risk patients, 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 serves as co-chair of the pod alongside the pod leader, helping drive and prioritize patient needs to improve outcomes. The position coordinates services and transitions across the care continuum, works with patients, caregivers, providers, and other care-team members, and supports access to personalized care. It includes conducting nursing assessments by telephone, reviewing records for care gaps, facilitating high-risk huddles, educating patients and caregivers, and documenting interactions and care-plan updates in medical records. The role requires clinical judgment, effective communication, and timely completion of duties and documentation.

Requirements

Active Registered Nurse license.
At least 2 years of care management experience in a community, health plan, or hospital system.
Strong clinical skills and proactive thinking.
Effective communication skills.
Ability to perform extensive telephone assessments.
Knowledge of Medicare regulations and home care and hospice standards.
Experience with small-group presentations and teaching or training.
Excellent interpersonal skills.
Excellent written and oral communication skills.
Working knowledge of computer programs such as email, Word, Excel, and PowerPoint.
Ability to manage time effectively and complete duties and documentation requirements 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 so patients can access services tailored to their needs throughout their healthcare journey.
Collaborate with the care team to develop and manage personalized care plans, address care gaps, and connect patients with resources.
Coordinate patient transitions throughout the continuum of care to meet patient needs 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 gaps in care 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 to promote self-management.
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.
Facilitate communication about patient status and care plans during transitions such as home to hospital, hospital to post-acute care, and back home.