RN Nurse Care Manager

HarmonyCares; Troy (MI); On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Quarterly Bonuses

Health Insurance

401K Retirement Plan

Tuition Reimbursement

Paid Time Off

Job summary

HarmonyCares in Troy, MI is seeking a Nurse Care Manager to join our care team delivering high-quality home-based primary care to patients with complex needs.

In this role you will coordinate care plans, conduct telephone assessments, educate patients and caregivers, and collaborate with pod leaders and the care team to improve health outcomes and reduce hospitalizations.

Qualifications

• Active RN license and current practice in care management.
• 2+ years managing high-risk patients in community or hospital settings.
• Strong clinical and proactive thinking; effective communication.
• Ability to perform extensive telephone assessments.
• Knowledge of Medicare regulations and home care standards.
• Experience with group presentations and teaching/training.
• Excellent interpersonal and written/oral communication skills.
• Proficient with email, Word, Excel, PowerPoint.

Responsibilities

• Coordinate care services with pod leader for comprehensive services.
• Develop and manage personalized care plans; close care gaps.
• Coordinate transitions of care to prevent readmissions.
• Facilitate High Risk Huddles and follow-up actions.
• Prioritize patients by severity to ensure urgent cases receive attention.
• Review medical records to identify gaps and coordinate services.
• Regularly update patient care plans.
• Conduct thorough nursing assessments via telephone.
• Educate patients and caregivers on disease management.
• Document interactions in medical records per guidelines.
• Serve as liaison between patients, providers, resources.
• Communicate patient status during transitions home and hospital.

Skills

Care management

Communication skills

Phone-based assessment

Interpersonal skills

Time management

Clinical assessments

Documentation

Education

Active RN license

Bachelor of Science in Nursing (BSN)

Tools

Microsoft Office

EMR/EHR systems

Job description

Overview

HarmonyCares is a leading national value-based provider of in-home primary care services for people with complex healthcare needs. Headquartered out of Troy, Michigan, HarmonyCares operates home-based primary care practices in 14 states. HarmonyCares employs more than 200+ primary care providers to deliver patient-centered care under an integrated, team-based, physician-driven model.

Our Mission– To bring personalized, quality-based healthcare to the home of patients who have difficult accessing care.

Our Shared Vision– Every patient deserves access to quality healthcare.

Our Values– The way we care is our legacy. Every interaction counts. Go the extra mile. Empower and support each other.

Why You Should Want to Work with Us

• Quarterly Bonuses
• Health, Dental, Vision, Disability & Life Insurance, and much more
• 401K Retirement Plan (with company match)
• Tuition, Professional License and Certification Reimbursement
• Paid Time Off, Holidays and Volunteer Time Paid
• Orientation and Training Day Time Hours (no holidays/weekends)
• Established in 11 states
• Largest home-based primary care practice in the US for over 28 years, making a huge impact in healthcare today!

More details about the benefits we offer can be found at https://careers.harmonycares.com/benefits.

Responsibilities

The Nurse Care Manager is an integral member of the care team and is vital to enhancing the health outcomes of HCMG patients. This position will manage a caseload of high-risk patients where he/she is responsible for managing their care and barriers. These duties will include, but are not limited to Transitional Care Management, Chronic Care Management, Disease Management Education, Medication Education, and the development and management of patient care plans. The Nurse Care Manager will serve as co-chair of the pod alongside the pod leader, focusing on driving and prioritizing patient needs to improve patient outcomes.

Essential Duties & Responsibilities

• Coordinates care services with pod leader to ensure that patients have access to a comprehensive set of services tailored to their needs throughout their healthcare journey
• Works collaboratively within the care team to develop and manage personalized care plans, address care gaps, and engage with other resources to ensure access to care
• Coordinates the transition of care for patients throughout the continuum to ensure patient needs are met accordingly and to ensure that avoidable hospital admissions do not occur
• Coordinates and facilitates High Risk Huddles along with ensuring that follow-up actions are completed
• Prioritizes patients based on the severity and urgency of their conditions to ensure that the most critical cases receive immediate attention
• Reviews medical records to identify gaps in care and coordinate services with the care team to manage these issues
• Regularly updates patient care plans
• Performs thorough nursing assessments via telephone of patients to maximize or improve current health outcomes
• Provides education to patients and/or their caregivers on disease education, medication, health maintenance, and disease prevention to promote self-management and improve health outcomes
• Demonstrates strong clinical skills, critical thinking abilities, and effective communication in their interactions with patients, caregivers, providers, fellow care team members, etc.
• Documents necessary interactions, assessments, updates, etc. in patient’s medical records according to processes and guidelines
• Serves as liaison between patients, providers, resources, etc. to ensure seamless care delivery
• Facilitates communication of patient status and plan of care during transitional experiences such as home to hospital, hospital to post-acute care and back to home

In this role you may work with. . .

• Executive Directors
• Market Leaders
• Pod Leaders
• Clinical Social Worker
• Patient Health Coordinator
• Population Health Team

Qualifications

Required Knowledge, Skills and Experience

• Active Registered Nurse License
• 2+ years of care management experience in community, health plan or hospital systems
• Possesses strong clinical skills and proactive thinking
• Effective communication skills
• Ability to perform extensive telephone assessment
• Knowledge of Medicare regulations and home care and hospice standards
• Experience with small group presentations and teaching/training
• Exhibits excellent interpersonal skills
• Exhibits excellent written and oral skills
• Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.)
• Manages time effectively to ensure all duties and documentation requirements are completed in a timely manner

Preferred Knowledge, Skills and Experience

• Bachelor of Science in nursing or related field
• May be required to obtain multi-state licensing
• Strong knowledge of population health, quality measures, care gap closure and value-based care models

Pay Transparency

Individual compensation packages are based on various factors unique to each candidate, including skill set, experience, qualifications, and other job-related considerations.