Nurse Care Manager

The role

The Nurse Care Manager provides care coordination for high-risk patients with chronic conditions. This field-based role involves in-person and telephonic outreach, medication reconciliation, and developing personalized care plans.

What you will do

• Coordinate care for high-risk patients requiring comprehensive care plans.
• Collaborate with a multidisciplinary Care Team to ensure optimal health outcomes.
• Focus on chronic care management and care transitions for patients discharged from inpatient settings.
• Conduct in-home and telephonic assessments, care plans, and medication reconciliations.
• Act as an advocate for patients and ensure integration of services across providers.
• Reach out to patients and caregivers within 48 hours of discharge.
• Provide education to patients and families about treatment options.
• Manage patient caseloads and prioritize tasks.
• Document care using EHR systems.
• Identify gaps in care and resolve issues through collaboration.

Required qualifications

• Registered nursing license (unrestricted)
• Minimum of three years of clinical nursing experience
• 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

Nice to have

• Experience in care management, case management, or transitional care settings
• Experience in acute care environments such as ICU, Med-Surg, or ER
• Case management certification

About the company

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