Telephonic Nurse Care Manager-RN

Overview

HarmonyCares is a leading national value-based provider of in-home primary care services for people with complex healthcare needs. Headquartered out of Troy, Michigan, HarmonyCares operates home-based primary care practices in 14 states. HarmonyCares employs more than 200+ primary care providers to deliver patient-centered care under an integrated, team-based, physician-driven model.

Our Mission

– To bring personalized, quality-based healthcare to the home of patients who have difficult accessing care.

Our Shared Vision

– Every patient deserves access to quality healthcare.

Our Values

– The way we care is our legacy. Every interaction counts. Go the extra mile. Empower and support each other.

Why You Should Want to Work with Us

Quarterly Bonuses

Health, Dental, Vision, Disability & Life Insurance, and much more

401K Retirement Plan (with company match)

Tuition, Professional License and Certification Reimbursement

Paid Time Off, Holidays and Volunteer Time Paid

Orientation and Training Day Time Hours (no holidays / weekends)

Great Place to Work Certified

Established in 11 states

Largest home-based primary care practice in the US for over 28 years, making a huge impact in healthcare today!

More details about the benefits we offer can be found at

https : / / careers.harmonycares.com / benefits .

Responsibilities

The Nurse Care Manager is an integral member of the care team and is vital to enhancing the health outcomes of HCMG patients. This position will manage a caseload of high-risk patients where he / she is responsible for managing their care and barriers. These duties will include, but are not limited to Transitional Care Management, Chronic Care Management, Disease Management Education, Medication Education, and the development and management of patient care plans. The Nurse Care Manager will serve as co-chair of the pod alongside the pod leader, focusing on driving and prioritizing patient needs to improve patient outcomes.

Essential Duties & Responsibilities

Coordinates care services with pod leader to ensure that patients have access to a comprehensive set of services tailored to their needs throughout their healthcare journey

Works collaboratively within the care team to develop and manage personalized care plans, address care gaps, and engage with other resources to ensure access to care

Coordinates the transition of care for patients throughout the continuum to ensure patient needs are met accordingly and to ensure that avoidable hospital admissions do not occur

Coordinates and facilitates High Risk Huddles along with ensuring that follow-up actions are completed

Prioritizes patients based on the severity and urgency of their conditions to ensure that the most critical cases receive immediate attention

Reviews medical records to identify gaps in care and coordinate services with the care team to manage these issues

Regularly updates patient care plans

Performs thorough nursing assessments via telephone of patients to maximize or improve current health outcomes

Provides education to patients and / or their caregivers on disease education, medication, health maintenance, and disease prevention to promote self-management and improve health outcomes

Demonstrates strong clinical skills, critical thinking abilities, and effective communication in their interactions with patients, caregivers, providers, fellow care team members, etc.

Documents necessary interactions, assessments, updates, etc. in patient’s medical records according to processes and guidelines

Serves as liaison between patients, providers, resources, etc. to ensure seamless care delivery

Facilitates communication of patient status and plan of care during transitional experiences such as home to hospital, hospital to post-acute care and back to home

In this role you may work with. . .

Executive Directors

Market Leaders

Pod Leaders

Clinical Social Worker

Patient Health Coordinator

Population Health Team

Qualifications

Required Knowledge, Skills and Experience

Active Registered Nurse License

2+ years of care management experience in community, health plan or hospital systems

Possesses strong clinical skills and proactive thinking

Effective communication skills

Ability to perform extensive telephone assessment

Knowledge of Medicare regulations and home care and hospice standards

Experience with small group presentations and teaching / training

Exhibits excellent interpersonal skills

Exhibits excellent written and oral skills

Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.)

Manages time effectively to ensure all duties and documentation requirements are completed in a timely manner

Preferred Knowledge, Skills and Experience

Bachelor of Science in nursing or related field

May be required to obtain multi-state licensing

Strong knowledge of population health, quality measures, care gap closure and value-based care models

Pay Transparency

Individual compensation packages are based on various factors unique to each candidate, including skill set, experience, qualifications, and other job-related considerations.