HarmonyCares

In-home healthcare provider delivering personalized care

Registered Nurse Nurse Care Manager

Medical, Clinical & VeterinaryConfirmed live in the last 24 hours

Full-timeVirginia Beach, VA, USA

About the Job

Requirements

An active Registered Nurse license is required.
At least 2 years of care management experience in community, health plan, or hospital systems is required.
Strong clinical skills and proactive thinking are required.
Effective communication skills are required.
The ability to perform extensive telephone assessments is required.
Knowledge of Medicare regulations and home care and hospice standards is required.
Experience with small-group presentations and teaching or training is required.
Working knowledge of computer programs, including email, Word, Excel, and PowerPoint, is required.
The ability to manage time effectively and complete duties and documentation requirements in a timely manner is required.

Responsibilities

Manage a caseload of high-risk patients, including their care and barriers to care.
Provide transitional care management, chronic care management, disease management education, and medication education, and develop and manage patient care plans.
Serve as co-chair of the pod alongside the pod leader, driving and prioritizing patient needs to improve patient outcomes.
Coordinate care services with the pod leader to ensure patients have access to comprehensive services tailored to their needs throughout their healthcare journey.
Work collaboratively within the care team to develop and manage personalized care plans, address care gaps, and engage other resources to ensure access to care.
Coordinate transitions of care throughout the continuum to meet patient needs and prevent avoidable hospital admissions.
Coordinate and facilitate high-risk huddles and ensure follow-up actions are completed.
Prioritize patients based on the severity and urgency of their conditions so critical cases receive immediate attention.
Review medical records to identify care gaps and coordinate with the care team to address them.
Regularly update patient care plans.
Perform thorough telephone nursing assessments to maximize or improve health outcomes.
Educate patients and caregivers on disease, medication, health maintenance, and disease prevention to promote self-management and improve health outcomes.
Document interactions, assessments, and updates in patient medical records according to processes and guidelines.
Serve as a liaison among patients, providers, and resources to ensure seamless care delivery.
Facilitate communication of patient status and care plans during transitions such as home to hospital, hospital to post-acute care, and back home.

Desired Qualifications

A Bachelor of Science in nursing or a related field is preferred.
The ability to obtain multi-state licensing may be required.
Strong knowledge of population health, quality measures, care gap closure, and value-based care models is preferred.

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)- 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

Posted Max Pay Rate

USD $90,000.00/Yr.

Posted Min Pay Rate

USD $73,605.89/Yr.

Pay Transparency

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

Compensation: 73605.89 to 90000 (USD)

About the Company

HarmonyCares

In-home healthcare provider delivering personalized care

HarmonyCares provides in-home healthcare across 14 states through partnerships with 150 provider networks, delivering personalized, compassionate medical, mental, physical, and spiritual care directly to patients at home. Its service model centers on integrated, high-quality care with custom care plans that support well-being and independence, while reducing barriers to access by bringing services to patients rather than requiring facility visits. Revenue comes from healthcare partnerships and direct service offerings to patients. Compared with traditional clinics, HarmonyCares differentiates itself by coordinating a broad network of providers and offering holistic, home-based care tailored to vulnerable groups such as the elderly and patients with chronic conditions. The company aims to improve patient well-being and independence by ensuring high-quality care is available in the comfort and privacy of patients’ homes.

Company size: 501-1,000
Company stage: Late Stage VC
Total funding: $200M
Headquarters: Troy, MI
Founded: 1993

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