Nurse Care Manager

Job Description

Job Description

Company Overview

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. Our clinical team addresses the physical, behavioral, and social health needs of patients when and where they need support.

Our team includes physicians, nurses, Care Specialists, and other professionals who work together to help patients navigate complex health needs, manage chronic conditions, overcome barriers to care, and achieve better health outcomes.

Job Title & Role Description

The Nurse Care Manager (RN) is responsible for managing and coordinating care for high-risk patients with complex medical, behavioral, and social needs.

This role is primarily work from home , with nurses managing their patient caseload through telephonic outreach, care coordination, clinical assessment, patient education, and collaboration with the multidisciplinary care team. Nurse Care Managers also have the autonomy to conduct in-home patient visits when they determine an in-person assessment or intervention is clinically necessary .

The Nurse Care Manager uses strong clinical judgment to identify patient needs, develop individualized care plans, support chronic disease management, and help patients safely transition home following hospitalizations and other acute-care episodes.

This role is ideal for an experienced RN who enjoys care management, values autonomy, and wants to build ongoing relationships with patients while helping them navigate the healthcare system.

What You'll Do

• Manage and coordinate care for a caseload of high-risk patients with chronic and complex health conditions
• Conduct telephonic assessments and ongoing patient outreach from a home-based work environment
• Complete in-home visits when clinically appropriate based on the patient's individual needs
• Develop and maintain individualized care plans addressing patients' medical, behavioral, and social health needs
• Support patients following hospital discharge and other transitions of care
• Conduct medication reconciliation and identify medication-related concerns or barriers
• Educate patients and caregivers about diagnoses, medications, treatment plans, and self-management strategies
• Identify gaps in care and work with patients, providers, and the multidisciplinary care team to address them
• Coordinate services across primary care providers, specialists, hospitals, pharmacies, outpatient services, and community resources
• Advocate for patients and help them navigate barriers within the healthcare system
• Monitor patient progress and adjust care plans based on changing clinical needs
• Document patient interactions, assessments, and interventions accurately and timely in the EHR
• Collaborate with Upward Health's multidisciplinary care team to ensure patients receive coordinated, whole-person care
• Prioritize patient needs and independently manage daily responsibilities across an assigned caseload

What We're Looking For Required Qualifications

• Active and unrestricted Registered Nurse (RN) license
• Minimum of 3 years of clinical nursing experience
• Strong clinical assessment, critical-thinking, and decision-making skills
• Ability to independently manage and prioritize a patient caseload
• Strong communication skills and ability to educate patients and caregivers
• Comfortable providing care management and patient support telephonically
• Comfortable conducting patient home visits when clinically necessary
• Experience using EHR systems and completing timely clinical documentation
• Comfortable using technology and digital communication tools in a primarily work-from-home environment
• Valid driver's license and auto liability insurance
• Reliable transportation and ability to travel within the assigned territory for patient visits as needed

Preferred Experience

Experience in one or more of the following areas is highly valued:

• Care management
• Case management
• Transitional care
• Chronic disease management
• Population health
• Home health or community-based nursing
• Med-Surg
• Emergency Department
• ICU or other acute-care environments

Case management certification is preferred but not required .

What Makes You Successful in This Role Clinical Judgment

You are comfortable independently assessing patient needs, identifying changes in condition, and determining the appropriate next steps, including when an in-home visit may be necessary.

Patient-Centered Care

You build meaningful relationships with patients and caregivers and take the time to understand the medical and non-medical barriers affecting their health.

Care Coordination

You can see the bigger picture of a patient's care and effectively coordinate across providers, hospitals, specialists, pharmacies, community resources, and other services.

Patient Education & Engagement

You can explain complex medical information in a way patients and caregivers understand and help patients become more confident managing their health.

Independence & Accountability

You are comfortable working primarily from home, organizing your day, managing a caseload, and making decisions independently while remaining connected to your care team.

Collaboration

You work closely with a multidisciplinary team and communicate proactively to make sure patients receive coordinated, comprehensive care.

Adaptability & Problem Solving

You recognize gaps and barriers in care and are comfortable finding solutions when a patient's needs or circumstances change.

The Nurse Care Manager Experience

As a Nurse Care Manager with Upward Health, your work is primarily home-based , giving you the flexibility to manage patient care remotely while still maintaining meaningful clinical involvement.

Rather than performing traditional bedside nursing, you'll focus on helping patients manage their health over time. You'll coordinate care, support patients after hospitalization, provide education, manage chronic conditions, address barriers, and use your nursing judgment to determine when additional intervention is needed.

When a patient's situation calls for face-to-face support, you'll have the ability to meet them in their home and provide an in-person assessment or intervention based on clinical need.

You'll have the independence to manage your patients while also having the support of a multidisciplinary team working toward the same goal: helping patients receive the right care at the right time.

Equal Opportunity Employer

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 provides a general outline of the responsibilities and qualifications associated with the position and is not intended to encompass every duty that may be performed.

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