RN Nurse Care Manager

HarmonyCares•Cincinnati, IA

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. Responsibilities include transitional care management, chronic care management, disease and medication education, and developing and managing patient care plans. The role also serves as co-chair of the pod alongside the pod leader, focusing on prioritizing patient needs and improving outcomes. The position coordinates services across the care team and healthcare continuum, identifies care gaps, facilitates high-risk huddles and follow-up, and helps prevent avoidable hospital admissions. The Nurse Care Manager conducts telephone nursing assessments, educates patients and caregivers, documents care in medical records, and serves as a liaison among patients, providers, and other resources. HarmonyCares is a national value-based provider of in-home primary care for people with complex healthcare needs. Its integrated, team-based, physician-driven model delivers patient-centered care in patients’ homes.

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 the 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 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 engage resources to ensure access to care.
Coordinate transitions of care across the continuum, meeting patient 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 services with the care team to address them.
Regularly update patient care plans.
Conduct thorough telephone nursing assessments to maximize or improve health outcomes.
Educate patients and caregivers about diseases, medications, health maintenance, and disease prevention.
Communicate effectively with patients, caregivers, providers, and care team members using clinical skills and critical thinking.
Document interactions, assessments, and updates in 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, including home to hospital, hospital to post-acute care, and return home.