RN Nurse Care Manager ( Hybrid)

HarmonyCares•Newark, NJ

2d•Hybrid

About The Position

HarmonyCares is a national provider of value-based, in-home primary care for people with complex healthcare needs. The Nurse Care Manager is an integral member of the care team, managing a caseload of high-risk patients and helping address their care needs and barriers. The role includes transitional care management, chronic care management, disease and medication education, and developing and managing patient care plans. The Nurse Care Manager also serves as co-chair of the care pod alongside the pod leader, helping drive and prioritize patient needs to improve outcomes. This position collaborates with the care team and other resources to coordinate services, close care gaps, support transitions across care settings, and prevent avoidable hospital admissions. It includes conducting telephone nursing assessments, educating patients and caregivers, documenting interactions in medical records, and serving as a liaison among patients, providers, and resources. The role is hybrid and offers day-time hours, with 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 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 engage resources to ensure access to care.
Coordinate patients’ transitions across the continuum of care, meeting their needs and helping 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 telephone nursing assessments to maximize or improve patient health outcomes.
Educate patients and caregivers about diseases, medications, health maintenance, and disease prevention to promote self-management and improve outcomes.
Use clinical skills, critical thinking, and effective communication with patients, caregivers, providers, and care team members.
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 of 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 care pod alongside the pod leader, focusing on driving and prioritizing patient needs.