RN Nurse Care Manager ( Hybrid )

HarmonyCares • Flint, MI

23h • Hybrid

About The Position

The Nurse Care Manager is an integral member of the care team and helps enhance health outcomes for HarmonyCares Medical Group patients. The position manages a caseload of high-risk patients, coordinating their care and addressing barriers. Responsibilities include transitional care management, chronic care management, disease and medication education, and developing and managing 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 role works collaboratively with pod leaders and care team members to coordinate services, address care gaps, support transitions across care settings, and help prevent avoidable hospital admissions. It includes telephone nursing assessments, patient and caregiver education, medical-record documentation, care-plan updates, high-risk huddles, and communication among patients, providers, and other resources.

The position is described as hybrid, with three days in the office. The posting states day-time hours and no holidays or weekends.

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 the 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, including 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 transitions of care throughout the continuum and help ensure patient needs are met and avoidable hospital admissions do not occur.
• 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.
• Educate patients and caregivers about diseases, medications, health maintenance, and disease prevention.
• 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.
• Serve as co-chair of the pod alongside the pod leader, focusing on driving and prioritizing patient needs.

Benefits

• Quarterly bonuses.
• Health, dental, vision, disability, and life insurance.
• 401(k) retirement plan with company match.
• Tuition, professional license, and certification reimbursement.
• Paid time off, holidays, and volunteer time.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed