Job Title & Role Description
The Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem. The Nurse Care Manager acts as an advocate for patients and ensures the integration of services across providers, hospitals, and outpatient services.
Skills Required
Expertise in care management and coordination across healthcare providers
Strong communication skills for patient and caregiver education
Ability to conduct both in-home and telephonic assessments, care plans, and medication reconciliations
Experience with EHR systems and real-time documentation
Ability to work independently and manage multiple patient cases
Critical thinking and decision-making skills in developing care plans
Proficient in using digital tools for care coordination and communication
A valid driver's license and auto liability insurance
Reliable transportation and the ability to travel within assigned territory or as needed
Case management certification is a plus but not required
Key Behaviors
Patient-Centered Care
Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.
Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.
Proactive Communication
Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.
Advocacy and Education
Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.
Care Coordination
Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.
Time Management
Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.
Problem Solving
Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.
Confidentiality
Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.
Cultural Competence
Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.
Clinical Expertise
Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.
Effective Communication
Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.
Care Plan Development
Proficient in creating personalized care plans that address physical, behavioral, and social health needs.
Technology Proficiency
Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.
Outcome-Oriented
Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.
Independent and Team-Oriented
Able to work independently in a remote environment while also collaborating effectively with a multidisciplinary team.
Critical Thinking
Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.
Multitasking and Prioritization
Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.
Motivates patients to follow care plans and improve self-care skills through regular communication and support.
Upward Health is proud to be an equal opportunity employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce.
This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position.