Nurse Care Manager

Overview 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, nurses, and Care Specialists to HR, Technology, and Business Services staff are driven by a desire to improve the lives of our patients. We treat a wide range of needs and believe health requires care for the whole person. 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 to ensure optimal health outcomes through personalized care plans, self-management, and disease prevention. The role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves 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. Responsibilities Coordinate care for high-risk patients with chronic conditions using personalized care plans. Collaborate with a multidisciplinary Care Team to achieve optimal health outcomes. Conduct in-person and telephonic outreach for care management, transitions, and follow-up. Perform medication reconciliation and ensure continuity of care across providers, hospitals, and outpatient services. Advocate for patients and support integration of services across the healthcare ecosystem. Qualifications Registered nursing license (unrestricted). Minimum of three years of clinical nursing experience. Preferred experience in care management, case management, or transitional care settings; experience in acute care environments (ICU, Med-Surg, ER) is valued. Expertise in care management and coordination across healthcare providers. Strong communication skills for patient and caregiver education. Ability to conduct 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. Proficiency in using digital tools for care coordination and communication. Valid driver’s license and auto liability insurance; reliable transportation and ability to travel within assigned territory as needed. Case management certification is preferred but not required. Key Behaviors Patient-Centered Care: Develops strong relationships with patients and caregivers, and helps patients follow care plans. Collaboration: Works effectively with the multidisciplinary Care Team to ensure seamless care. Proactive Communication: Reaches out to patients and caregivers within 48 hours of discharge to support transitions. Advocacy and Education: Provides clear education to patients and families about treatment options, empowering self-management. Care Coordination: Coordinates care across multiple providers and services, especially during transitions of care. Time Management: Manages patient caseloads and deadlines while following care plans. Problem Solving: Identifies gaps in care and resolves issues through collaboration with providers. Confidentiality: Maintains patient confidentiality and HIPAA compliance. Cultural Competence: Delivers culturally sensitive care to diverse populations. Competencies Clinical Expertise: Knowledge of chronic disease management, care transitions, and evidence-based practices. Effective Communication: Clearly conveys medical information to patients, caregivers, and interdisciplinary teams. Care Plan Development: Creates personalized plans addressing physical, behavioral, and social health needs. Technology Proficiency: Uses EHR and care management systems to document and coordinate care. Outcome Orientation: Aims for optimal clinical and financial outcomes through coordination. Independent and Team-Oriented: Works independently in the field and collaborates with a team. Critical Thinking: Applies clinical judgment to assess and adjust care plans. Multitasking and Prioritization: Manages multiple cases and tasks to meet deadlines. Patient Engagement: Motivates patients to follow care plans and improve self-care skills. Upward Health is an equal opportunity employer. This job description describes duties performed and is not all-encompassing. California pay range: $100,000 USD - $105,000 USD. #J-18808-Ljbffr