RN Nurse Care Manager, Hybrid

About the role

HarmonyCares is a leading national value-based provider of in-home primary care services for people with complex healthcare needs. Our mission is to bring personalized, quality-based healthcare to the home of patients who have difficulty accessing care. We operate home-based primary care practices in 14 states, employing over 200 primary care providers under an integrated, team-based, physician-driven model.

As a Nurse Care Manager, you will be an integral member of the care team, vital to enhancing the health outcomes of our patients. This position manages a caseload of high-risk patients, focusing on care coordination, transitional care management, chronic care management, and patient education. You will serve as co-chair of the pod alongside the pod leader, driving and prioritizing patient needs to improve outcomes.

Responsibilities

• Coordinates care services with pod leader to ensure patients have access to a comprehensive set of services tailored to their needs throughout their healthcare journey.
• Works collaboratively within the care team to develop and manage personalized care plans, address care gaps, and engage with resources to ensure access to care.
• Coordinates the transition of care for patients throughout the continuum to prevent avoidable hospital admissions.
• Coordinates and facilitates High Risk Huddles, ensuring follow-up actions are completed.
• Prioritizes patients based on the severity and urgency of their conditions to ensure critical cases receive immediate attention.
• Reviews medical records to identify gaps in care and coordinates services with the care team to manage these issues.
• Regularly updates patient care plans.
• Performs thorough nursing assessments via telephone to maximize or improve current health outcomes.
• Provides education to patients and/or caregivers on disease management, medication, health maintenance, and disease prevention to promote self-management and improve health outcomes.
• Demonstrates strong clinical skills, critical thinking abilities, and effective communication in interactions with patients, caregivers, providers, and care team members.
• Documents interactions, assessments, and updates in patient medical records according to processes and guidelines.
• Serves as a liaison between patients, providers, and resources to ensure seamless care delivery.
• Facilitates communication of patient status and plan of care during transitional experiences (e.g., home to hospital, hospital to post-acute care, and back to home).

In this role, you may collaborate with Executive Directors, Market Leaders, Pod Leaders, Clinical Social Workers, Patient Health Coordinators, and the Population Health Team.

Requirements

• 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, written, and oral skills.
• Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.).
• Ability to manage time effectively to complete all duties and documentation requirements in a timely manner.

Preferred Qualifications

• Bachelor of Science in Nursing or 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.

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.
• Orientation and training.
• Daytime hours (no holidays/weekends).
• Great Place to Work Certified.

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.