RN Nurse Care Manager

HarmonyCares•Virginia Beach, VA

22d•$73,606 - $81,022

About The Position

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. Responsibilities include 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 pod alongside the pod leader, focusing on prioritizing patient needs and improving outcomes. The position coordinates tailored care services and transitions across the healthcare continuum, works with the care team to address care gaps, and ensures follow-up actions are completed. It includes conducting telephone nursing assessments, educating patients and caregivers, reviewing medical records, documenting interactions, and serving as a liaison among patients, providers, and care resources. The role collaborates with executive directors, market leaders, pod leaders, clinical social workers, patient health coordinators, and the population health team. HarmonyCares is a national provider of in-home primary care for people with complex healthcare needs. It operates home-based primary care practices in 14 states and employs more than 200 primary care providers. The organization describes its model as integrated, team-based, and physician-driven.

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, 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 multistate 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 have access to 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 support access to care.
Coordinate patient transitions across the continuum 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 care gaps and coordinate services 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 when interacting 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.
Manage a caseload of high-risk patients and their care needs and barriers.
Serve as co-chair of the pod alongside the pod leader, helping drive and prioritize patient needs.