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Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. Our clinical team treats physical, behavioral, and social health needs when and where a patient needs help. Everyone on our team—from doctors and nurses to Care Specialists and support staff—is driven by a desire to improve patients' lives. We address a wide range of needs, from managing blood sugar to mental health and accessing tailored meals, because health encompasses the whole person. 98% of patients report being fully satisfied with Upward Health!
Job Title & Role Description
The Nurse Care Manager is responsible for care coordination of high-risk patients requiring comprehensive care plans for chronic conditions. The role involves working with a multidisciplinary Care Team Pod to ensure optimal health outcomes through personalized care plans, self-management support, and disease prevention. Focus areas include care transitions, especially for discharged patients, telephonic outreach, medication reconciliation, and ensuring continuity of care across providers and services. The Nurse Care Manager advocates for patients and facilitates service integration across the healthcare ecosystem.
Skills Required
Registered nursing license (unrestricted)
Expertise in care management and coordination across healthcare providers
Strong communication skills for patient and caregiver education
Ability to conduct telephonic assessments, develop care plans, and perform medication reconciliation
Experience with EHR systems and real-time documentation
Ability to work independently and manage multiple patient cases
Critical thinking and decision-making skills for developing care plans
Proficiency in digital tools for care coordination and communication
Key Behaviors
Patient-Centered Care: Develops strong relationships with patients and caregivers, advocating for their needs and ensuring understanding and adherence to care plans.
Collaboration: Works effectively with the multidisciplinary Care Team Pod for seamless care across providers and services.
Proactive Communication: Reaches out within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.
Advocacy And Education: Provides compassionate education about treatment options, empowering patients to manage their health.
Care Coordination: Coordinates care effectively across multiple providers, especially during transitions.
Time Management: Manages multiple cases efficiently, adhering to deadlines and care plans.
Problem Solving: Identifies care gaps, resolves issues collaboratively, and works to optimize outcomes.
Confidentiality: Maintains patient privacy in compliance with HIPAA regulations.
Cultural Competence: Demonstrates respect for diversity and provides culturally sensitive care.
Competencies
Clinical Expertise: Knowledge of chronic disease management, care transitions, and evidence-based practices.
Effective Communication: Clearly delivers complex medical information to patients and teams.
Care Plan Development: Creates personalized plans addressing physical, behavioral, and social needs.
Technology Proficiency: Uses EHR and care management systems effectively.
Outcome-Oriented: Focused on achieving optimal clinical and financial results.
Independent and Team-Oriented: Works remotely and collaborates effectively with teams.
Critical Thinking: Uses clinical judgment to assess and adapt care plans.
Multitasking and Prioritization: Manages multiple cases efficiently.
Patient Engagement: Motivates and supports patients in following care plans.
Upward Health is proud to be an equal opportunity employer, committed to diversity and inclusion. This job description outlines typical duties but is not exhaustive.