RN Care Manager - Home-Based Primary Care (Hybrid)

HarmonyCares; Roanoke (VA); Hybrid; USD 74,000 - 90,000; Full time

Benefits offered by this job

Quarterly bonuses

Health, dental, vision, disability & 5

Job summary

HarmonyCares is seeking an RN Nurse Care Manager to join our hybrid team in Roanoke, VA. You will manage high-risk patients, coordinate transitions of care, and educate patients and caregivers to improve health outcomes.

Responsibilities include developing personalized care plans, leading care coordination with pod leaders, and ensuring timely documentation. Must have an active RN license and 2+ years in care management. Strong communication and scheduling skills required.

Qualifications

• Active Registered Nurse license required with 2+ years care management experience.
• Strong clinical skills and proactive thinking.
• Effective communication and telephone assessment abilities.
• Knowledge of Medicare regulations and home care standards.
• Experience with presentations and training.
• Excellent written and oral communication and interpersonal skills.
• Working knowledge of computer programs (email, Word, Excel, PowerPoint).
• Time management to complete documentation promptly.

Responsibilities

• Coordinate care services with pod leader to tailor services across the patient journey.
• Develop and manage personalized care plans and close care gaps.
• Coordinate transitions of care to reduce avoidable hospital admissions.
• Lead High Risk Huddles and ensure follow-up actions are completed.
• Prioritize patients by severity to ensure urgent cases get attention.
• Review medical records to identify gaps and coordinate services.
• Regularly update patient care plans and document interactions.
• Conduct thorough telephone nursing assessments and patient education.
• Document interactions in medical records per guidelines.
• Serve as liaison between patients, providers and resources for seamless care.
• Facilitate communication during transitions home, hospital, and post-acute care.

Skills

Active RN License

Care management

Effective communication

Telephone assessment

Time management

Interpersonal skills

Education

BSN / Bachelor of Science in Nursing

Tools

Microsoft Office

Job description

HarmonyCares is seeking an RN Nurse Care Manager to join our hybrid team in Roanoke, VA. You will manage high-risk patients, coordinate transitions of care, and educate patients and caregivers to improve health outcomes.

Responsibilities include developing personalized care plans, leading care coordination with pod leaders, and ensuring timely documentation. Must have an active RN license and 2+ years in care management. Strong communication and scheduling skills required.