RN Nurse Care Manager ( Hybrid )

HarmonyCares•Flint Charter Township, MI

21h•Hybrid

About The Position

The Nurse Care Manager is an integral member of the care team and manages a caseload of high-risk patients, addressing their care needs and barriers. The role includes 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 position coordinates services and transitions across the healthcare continuum, collaborates with the care team and other resources, identifies care gaps, and keeps patient care plans current. It also includes telephone nursing assessments, patient and caregiver education, facilitating high-risk huddles and follow-up, documenting interactions in medical records, and serving as a liaison among patients, providers, and resources. The role works with executive directors, market leaders, pod leaders, clinical social workers, patient health coordinators, and the population health team. The posting specifies three days in the office.

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, written, and oral communication skills.
Working knowledge of computer programs such as 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 patient transitions throughout the continuum of care, helping ensure 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 services with the care team to address them.
Regularly update patient care plans.
Perform thorough nursing assessments of patients by telephone to maximize or improve health outcomes.
Educate patients and/or caregivers about diseases, medications, health maintenance, and disease prevention to promote self-management and improve outcomes.
Communicate effectively with patients, caregivers, providers, and care team members using clinical skills and critical thinking.
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.
Manage a caseload of high-risk patients, including Transitional Care Management, Chronic Care Management, and disease management education.