RN Nurse Care Manager

HarmonyCares•Reading, PA

2d•Remote

About The Position

HarmonyCares is a leading national value-based provider of in-home primary care services for people with complex healthcare needs. Headquartered out of Troy, Michigan, HarmonyCares operates home-based primary care practices in 14 states. HarmonyCares employs more than 200+ primary care providers to deliver patient-centered care under an integrated, team-based, physician-driven model. Our Mission– To bring personalized, quality-based healthcare to the home of patients who have difficult accessing care. Our Shared Vision– Every patient deserves access to quality healthcare. Our Values– The way we care is our legacy. Every interaction counts. Go the extra mile. Empower and support each other.

Requirements

Active Registered Nurse License
2+ years of care management experience in community, health plan or hospital systems
Strong clinical skills and proactive thinking
Effective communication skills
Ability to perform extensive telephone assessment
Knowledge of Medicare regulations and home care and hospice standards
Experience with small group presentations and teaching/training
Excellent interpersonal skills
Excellent written and oral skills
Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.)
Effective time management to ensure all duties and documentation requirements are completed in a timely manner

Nice To Haves

Bachelor of Science in nursing or 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

Manage a caseload of high-risk patients, overseeing their care and addressing barriers.
Conduct Transitional Care Management, Chronic Care Management, Disease Management Education, and Medication Education.
Develop and manage patient care plans.
Serve as co-chair of the pod alongside the pod leader, focusing on driving and prioritizing patient needs to improve patient outcomes.
Coordinate care services with the pod leader to ensure patients have access to a comprehensive set of services tailored to their needs.
Work collaboratively within the care team to develop and manage personalized care plans, address care gaps, and engage with other resources.
Coordinate the transition of care for patients throughout the continuum to ensure patient needs are met and to prevent avoidable hospital admissions.
Coordinate and facilitate High Risk Huddles and ensure follow-up actions are completed.
Prioritize patients based on the severity and urgency of their conditions.
Review medical records to identify gaps in care and coordinate services with the care team.
Regularly update patient care plans.
Perform thorough nursing assessments via telephone to improve current health outcomes.
Provide education to patients and/or their caregivers on disease education, medication, health maintenance, and disease prevention.
Demonstrate strong clinical skills, critical thinking abilities, and effective communication.
Document necessary interactions, assessments, and updates in patient’s medical records.
Serve as a liaison between patients, providers, and resources.
Facilitate communication of patient status and plan of care during transitional experiences.