Nurse Care Manager — Home-Based Primary Care

HarmonyCares; Virginia Beach (VA); On-site; USD 74,000 - 81,000; Full time

Benefits offered by this job

Quarterly bonuses

Health & dental insurance

401K plan with match

Tuition reimbursement

Paid time off

Training & orientation

Established in 11 states

Industry leader in home-based care

Job summary

HarmonyCares is seeking a Nurse Care Manager (RN) to join our home-based care team serving high-need patients in Virginia Beach, VA. You will manage a caseload, coordinate care with pod leaders, and guide transitions across the care continuum to improve outcomes.

In this role you will educate patients and caregivers, review records, and develop tailored care plans while leveraging our multidisciplinary pod.

Qualifications

• Active Registered Nurse License is required.
• At least 2 years of care management experience in community, health plan or hospital systems.
• Strong clinical and proactive thinking skills.
• Excellent communication skills.
• Experience with telephone assessments.
• Knowledge of Medicare regulations and home care/hospice standards.
• Experience with presentations and training.
• Excellent interpersonal skills.
• Proficient in common computer programs (email, Word, Excel, PowerPoint).
• Time management to meet documentation deadlines.

Responsibilities

• Coordinate care services with pod leader for comprehensive services.
• Develop and manage personalized care plans and address gaps.
• Oversee transition of care to avoid avoidable hospital admissions.
• Facilitate High Risk Huddles and follow-up actions.
• Prioritize patients by severity to ensure timely attention.
• Review medical records to identify gaps and coordinate services.
• Update patient care plans regularly.
• Conduct thorough nursing telephone assessments.
• Educate patients and caregivers on disease management.
• Document interactions in medical records per guidelines.
• Liaise between patients, providers and resources.
• Communicate patient status during transitions home/hospital.

Skills

Active RN License

Care coordination

Communication skills

Telephone assessment

Time management

Medicare regulations knowledge

Proactive thinking

Education

BSN preferred

Tools

Microsoft Office

Job description

HarmonyCares is seeking a Nurse Care Manager (RN) to join our home-based care team serving high-need patients in Virginia Beach, VA. You will manage a caseload, coordinate care with pod leaders, and guide transitions across the care continuum to improve outcomes.

In this role you will educate patients and caregivers, review records, and develop tailored care plans while leveraging our multidisciplinary pod.