RN Care Manager — In-Home Primary Care Leader

HarmonyCares; Flint (MI); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Quarterly bonuses

Health insurance

Dental insurance

Vision insurance

Disability & Life insurance

401K with company match

Tuition reimbursement

Paid time off

Holidays

Volunteer time off

Training hours

Job summary

HarmonyCares is seeking a Nurse Care Manager to join the care team and manage a caseload of high-risk patients. You will oversee Transitional Care Management, Chronic Care Management, and Disease Management Education, while developing and managing patient care plans and serving as co-chair of the pod with the pod leader.

You will drive patient needs, coordinate with the care team, and ensure timely follow-up actions, documentation, and communication to improve health outcomes in a home-based

Qualifications

• Active RN license and clinical nursing background.
• 2+ years of care management experience in community, health plan or hospital systems.
• Strong clinical and proactive thinking abilities.
• Excellent communication, both written and verbal.

Responsibilities

• Coordinate care services with pod leader to provide tailored services across the patient care journey.
• Develop and manage personalized care plans, address care gaps, and liaise with resources.
• Coordinate transitions of care to avoid unnecessary hospital admissions.
• Lead High Risk Huddles and ensure follow-up actions are completed.
• Prioritize patients based on severity to address urgent needs.
• Review medical records to identify gaps and coordinate services.
• Regularly update patient care plans and document interactions in the medical record.
• Provide disease, medication, health maintenance education to patients and caregivers.

Skills

Active RN license

Care management experience

Clinical skills

Communication skills

Telephone assessment

Medicare/home care knowledge

Teaching/training

Interpersonal skills

Written and oral skills

Computer programs (email, Word, Excel,

Time management

Education

BSN preferred

Multi-state licensing

Tools

Microsoft Office

Job description

HarmonyCares is seeking a Nurse Care Manager to join the care team and manage a caseload of high-risk patients. You will oversee Transitional Care Management, Chronic Care Management, and Disease Management Education, while developing and managing patient care plans and serving as co-chair of the pod with the pod leader.

You will drive patient needs, coordinate with the care team, and ensure timely follow-up actions, documentation, and communication to improve health outcomes in a home-based