Telephonic Nurse Care Manager

HarmonyCares is one of the nation’s largest home-based primary care practices. HarmonyCares is a family of companies all dedicated to providing high-quality, coordinated health care in the home. This includes HarmonyCares, HarmonyCares Medical Group, HarmonyCares Home Health and HarmonyCares Hospice. 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.

The Nurse Care Manager works closely with HarmonyCares Medical Group (HCMG) in home health care continuum and specialty services to maximize the health of the 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 Transitional Care Management, Chronic Care Management of the HCMG patients. The Nurse Care Manager’s primary responsibility involves overseeing a caseload of high-rish patients, where they play a crucial role in managing not only the patients’ care but also addressing any potential barriers to their well-being. This entails executing tasks such as Transitional Care Management and Chronic Care Management to ensure comprehensive and effective healthcare support. Essential Duties & Responsibilities Provides clinical coordination Prioritize patients based on the severity and urgency of their conditions. Triage is crucial in high acuity settings to ensure that the most critical cases receive immediate attention Demonstrate strong clinical skills, critical thinking abilities, and effective communication Prioritize nursing interventions based on the severity of the patient's condition Collaborate with the patient and multidisciplinary team to develop an individualized care plan based on the identified goals and needs and allocate tasks and interventions to the appropriate team members based on their experience Collaborates in patient care planning process to assess, monitor and evaluate options and services to meet health needs Implements a comprehensive clinical care management plan for each patient. Analyses variances from plan and initiates steps to resolve such variances Spend quality time with our patients and families identifying gaps in care, providing education, and partnering with our continuum in an effort to reduce unplanned hospitalizations and help ensure the right care at the right time