In-Home RN Care Manager | Value-Based Care

HarmonyCares; Newark (NJ); On-site; USD 85,000 - 93,000; Full time

Benefits offered by this job

Quarterly bonuses

Health insurance

401K with match

Tuition reimbursement

Paid time off

Job summary

HarmonyCares is seeking a Nurse Care Manager to join our home-based primary care team in the United States. You will manage a caseload of high-risk patients, overseeing Transitional Care Management, Chronic Care Management, disease and medication education, and the creation of patient care plans to improve outcomes.

You will serve as co-chair of the pod with the pod leader, driving patient needs and prioritizing care to enhance results, while maintaining thorough documentation in the medical

Qualifications

• Active RN license
• 2+ years of care management experience
• Strong clinical and proactive thinking
• Effective communication skills
• Ability to perform extensive telephone assessments
• Knowledge of Medicare regulations and home care standards
• Experience with small group presentations and training
• Excellent interpersonal skills
• Proficiency with Word, Excel, PowerPoint

Responsibilities

• Coordinates care services with pod leader to tailor services across the patient journey
• Develops and manages personalized care plans, addresses care gaps, and coordinates resources
• Manages transitions of care to prevent avoidable hospital admissions
• Facilitates High Risk Huddles and ensures follow-up actions
• Prioritizes patients by severity to ensure urgent cases receive attention
• Reviews medical records to identify gaps and coordinates services
• Documents interactions and updates in patient records according to guidelines
• Liaises between patients, providers, and resources to ensure seamless care delivery

Skills

Active RN license

Care management experience

Communication skills

Telephone assessment

Medicare knowledge

Tech literacy

Education

Bachelor of Science in Nursing

Tools

MS Office

Job description

HarmonyCares is seeking a Nurse Care Manager to join our home-based primary care team in the United States. You will manage a caseload of high-risk patients, overseeing Transitional Care Management, Chronic Care Management, disease and medication education, and the creation of patient care plans to improve outcomes.

You will serve as co-chair of the pod with the pod leader, driving patient needs and prioritizing care to enhance results, while maintaining thorough documentation in the medical