RN Nurse Care Manager

HarmonyCares • Roanoke, VA

2d

About The Position

The Nurse Care Manager is an integral member of the care team, managing a caseload of high-risk patients and addressing their care needs and barriers. The role supports patient health outcomes through Transitional Care Management, 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, focusing on prioritizing patient needs and improving outcomes.

The role coordinates services and transitions across the healthcare continuum, collaborates with the care team to address care gaps and connect patients with resources, and provides telephone nursing assessments and education to patients and caregivers. It also includes facilitating high-risk huddles, reviewing medical records, maintaining care plans and documentation, and serving as a liaison among patients, providers, and other resources.

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 excellent interpersonal, written, and oral 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.
• Working knowledge of computer programs such as 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 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 to provide patients with comprehensive 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 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 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.
• Communicate effectively with patients, caregivers, providers, and other care team members.
• Document interactions, assessments, and updates in patient medical records according to applicable 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, including home to hospital, hospital to post-acute care, and back home.

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 paid volunteer time.
• Orientation and training day hours with no holidays or weekends.

What This Job Offers

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