RN Nurse Care Manager ( Hybrid)

HarmonyCares • Cincinnati, OH

3d • Hybrid

About The Position

HarmonyCares is a national value-based provider of in-home primary care for people with complex healthcare needs. The RN Nurse Care Manager is an integral member of the care team who manages a caseload of high-risk patients, their care, and barriers to care. The role includes transitional and 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, helping drive and prioritize patient needs to improve outcomes.

The position coordinates services and transitions across the healthcare continuum, collaborates with the care team to address care gaps, and facilitates high-risk huddles and follow-up. It involves conducting telephone nursing assessments, educating patients and caregivers, documenting interactions and assessments, and serving as a liaison among patients, providers, and other resources. The role is hybrid, with 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 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 and 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 to provide patients with a comprehensive set of services tailored to their needs.
• 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 healthcare continuum 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 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.
• 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.
• Work with Executive Directors, Market Leaders, Pod Leaders, Clinical Social Workers, Patient Health Coordinators, and the Population Health Team.

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
• Career Level: Mid Level
• Education Level: No Education Listed