Nurse Care Manager

The role

The Nurse Care Manager manages and coordinates care for high-risk patients with complex medical, behavioral, and social needs. This role involves telephonic outreach, clinical assessment, and patient education, with the autonomy to conduct in-home visits when clinically necessary.

What you will do

• Manage and coordinate care for a caseload of high-risk patients
• Conduct telephonic assessments and ongoing patient outreach
• Complete in-home visits when clinically appropriate
• Develop and maintain individualized care plans
• Support patients following hospital discharge and other transitions of care
• Conduct medication reconciliation and identify medication-related concerns
• Educate patients and caregivers about diagnoses, medications, and treatment plans
• Identify gaps in care and work with the multidisciplinary team to address them
• Coordinate services across providers, hospitals, pharmacies, and community resources
• Document patient interactions and assessments in the EHR

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
• Valid driver's license and auto liability insurance
• Reliable transportation and ability to travel within the assigned territory

Nice to have

• 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

About the company

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. Their clinical team addresses physical, behavioral, and social health needs.