Job Description

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 our doctors, nurses, and Care Specialists to our HR, Technology, and Business Services staff are driven by a desire to improve the lives of our patients. We are able to treat a wide range of needs – everything from addressing poorly controlled blood sugar to combatting anxiety to accessing medically tailored meals – because we know that health requires care for the whole person. It’s no wonder 98% of patients report being fully satisfied with Upward Health!

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, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both 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.

Skills Required:

• Registered nursing license (unrestricted)
• 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
• Case management certification is a plus but not required

Key Behaviors:

Patient-Centered Care:

• Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.

Collaboration: 

• Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.

Proactive Communication: 

• Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.

Advocacy and Education: 

• Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.

Care Coordination: 

• Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.

Time Management: 

• Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.

Problem Solving: 

• Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.

Confidentiality: 

• Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.

Cultural Competence: 

• Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.

Competencies:

Clinical Expertise: 

• Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.

Effective Communication: 

• Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.

Care Plan Development: 

• Proficient in creating personalized care plans that address physical, behavioral, and social health needs.

Technology Proficiency: 

• Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.

Outcome-Oriented: 

• Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.

Independent and Team-Oriented: 

• Able to work independently in a remote environment while also collaborating effectively with a multidisciplinary team.

Critical Thinking: 

• Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.

Multitasking and Prioritization: 

• Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.

Patient Engagement: 

• Motivates patients to follow care plans and improve self-care skills through regular communication and support.

Upward Health is proud to be an equal opportunity employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position.

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