In-Home RN Care Manager: Patient Care Lead

HarmonyCares; Cave Spring (VA); On-site; USD 74,000 - 90,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

401K retirement plan with companymatch

Tuition and certification reimbursemen

Paid time off and holidays

Training and orientation

Job summary

HarmonyCares is seeking a Nurse Care Manager to join our home-based primary care network. You will manage a high-risk caseload, drive care plans, conduct education, and coordinate transitions across care settings to improve outcomes.

You will co-chair the pod with the pod leader, collaborate with the care team, and ensure timely documentation and communication while supporting patients and caregivers. RN license required; 2+ years in care management.

Qualifications

• Active RN license.
• 2+ years of care management experience.
• Strong clinical skills and proactive thinking.
• Excellent communication skills.
• Ability to perform extensive telephone assessment.
• Knowledge of Medicare regulations and home care/hospice standards.
• Experience with small group presentations and teaching/training.
• Excellent interpersonal skills and written/oral communication.
• Proficiency with common computer programs (email, Word, Excel, PowerPoint).
• Able to manage time effectively to complete duties and documentation.

Responsibilities

• Coordinates care services with pod leader to ensure comprehensive services throughout the patient journey.
• Collaborates with the care team to develop and manage personalized care plans and close care gaps.
• Manages transition of care to prevent avoidable hospital admissions.
• Coordinates and facilitates High Risk Huddles and follows up on actions.
• Prioritizes patients by severity to ensure timely attention for critical cases.
• Reviews medical records to identify gaps and coordinate care with the team.
• Regularly updates patient care plans.
• Performs thorough nursing assessments via telephone to improve outcomes.
• Educates patients and caregivers on disease management, medications, and self-care.
• Documents interactions and plans in the medical record per guidelines.
• Acts as liaison among patients, providers, and resources to ensure seamless care.

Skills

RN License

Care management

Clinical skills

Communication

Telephone assessment

Medicare regulations

Teaching/training

Interpersonal skills

Written and oral skills

Time management

EHR literacy

Education

Bachelor of Science in Nursing

Multi-state licensure

BSN preferred

Tools

Microsoft Office

Job description

HarmonyCares is seeking a Nurse Care Manager to join our home-based primary care network. You will manage a high-risk caseload, drive care plans, conduct education, and coordinate transitions across care settings to improve outcomes.

You will co-chair the pod with the pod leader, collaborate with the care team, and ensure timely documentation and communication while supporting patients and caregivers. RN license required; 2+ years in care management.