RN Nurse Care Manager

HarmonyCares is a leading national value-based provider of in-home primary care services for people with complex healthcare needs. Headquartered in Troy, Michigan, HarmonyCares operates home-based primary care practices in 14 states and employs over 200 primary care providers to deliver patient-centered care under an integrated, team-based, physician-driven model.

About Us

• Mission: To bring personalized, quality-based healthcare to the home of patients who have difficulty accessing care.
• Vision: Every patient deserves access to quality healthcare.
• Values: The way we care is our legacy. Every interaction counts. Go the extra mile. Empower and support each other.

HarmonyCares is the largest home-based primary care practice in the U.S. for over 28 years, making a significant impact in healthcare today.

Responsibilities

The Nurse Care Manager is an integral member of the care team and is vital to enhancing the health outcomes of patients. This position manages a caseload of high-risk patients and is responsible for managing their care and barriers, including:

• Transitional Care Management
• Chronic Care Management
• Disease Management Education
• Medication Education
• Development and management of patient care plans

Additional duties include:

• Coordinating care services with the pod leader to ensure patients have access to a comprehensive set of services tailored to their needs throughout their healthcare journey
• Collaborating within the care team to develop and manage personalized care plans, address care gaps, and engage with other resources to ensure access to care
• Coordinating the transition of care for patients throughout the continuum to prevent avoidable hospital admissions
• Facilitating High Risk Huddles and ensuring follow-up actions are completed
• Prioritizing patients based on the severity and urgency of their conditions
• Reviewing medical records to identify gaps in care and coordinate services with the care team
• Regularly updating patient care plans
• Performing thorough nursing assessments via telephone to maximize or improve current health outcomes
• Providing education to patients and/or caregivers on disease management, medication, health maintenance, and disease prevention
• Demonstrating strong clinical skills, critical thinking abilities, and effective communication
• Documenting necessary interactions, assessments, and updates in patient’s medical records
• Serving as a liaison between patients, providers, and resources to ensure seamless care delivery
• Facilitating communication of patient status and plan of care during transitional experiences

In this role, you may work with:

• Executive Directors
• Market Leaders
• Pod Leaders
• Clinical Social Worker
• Patient Health Coordinator
• Population Health Team

Requirements

Required Knowledge, Skills, and Experience:

• Active Registered Nurse License
• 2+ years of care management experience in community, health plan, or hospital systems
• 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/training
• Excellent interpersonal skills
• Excellent written and oral skills
• Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.)
• Effective time management to ensure all duties and documentation requirements are completed in a timely manner

Preferred Knowledge, Skills, and Experience:

• Bachelor of Science in Nursing or related field
• Multi-state licensing (may be required)
• Strong knowledge of population health, quality measures, care gap closure, and value-based care models

Benefits

• Quarterly Bonuses
• Health, Dental, Vision, Disability, and Life Insurance
• 401K Retirement Plan (with company match)
• Tuition, Professional License, and Certification Reimbursement
• Paid Time Off, Holidays, and Volunteer Time
• Paid Orientation and Training
• Daytime Hours (no holidays/weekends)

More details about the benefits we offer can be found at https://careers.harmonycares.com/benefits.

Pay

Individual compensation packages are based on various factors unique to each candidate, including skill set, experience, qualifications, and other job-related considerations.