Upward Health
Overview
Company Overview:
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. We are driven by a desire to improve the lives of our patients across doctors, nurses, Care Specialists, HR, Technology, and Business Services staff. Our approach addresses a wide range of needs—from poorly controlled chronic conditions to anxiety to medically tailored meals—because health requires care for the whole person. Upward Health is proud to be an equal opportunity employer and values a diverse and inclusive workforce. Compensation:
Base pay range: $100,000.00/yr - $105,000.00/yr Job Title & Role Description
The
Nurse Care Manager
is responsible for telephonic care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team Pod, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on care transitions, particularly for patients discharged from inpatient settings, and involves 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. Responsibilities
Provide telephonic care coordination for high-risk patients; develop and monitor comprehensive care plans addressing chronic conditions; support care transitions and post-discharge follow-up; perform medication reconciliation; ensure continuity of care across providers, hospitals, and outpatient services; advocate for patients and coordinate services to improve outcomes. Qualifications & Skills
Expertise in care management and coordination across healthcare providers Strong communication skills for patient and caregiver education Ability to conduct telephonic assessments, care plans, and medication reconciliation 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 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. 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. Clinical Expertise: Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans. Effective Communication: Delivers 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 Orientation: Focused on achieving optimal clinical and financial outcomes through effective care coordination and management. Independent and Team-Oriented: Able to work independently in a remote environment while collaborating with a multidisciplinary team. Critical Thinking: Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed. Multitasking and Prioritization: Manages multiple patient cases and prioritizes tasks to meet deadlines and ensure comprehensive care. Employment Type & Industry
Employment type: Full-time Job function: Health Care Provider Industry: Hospitals and Health Care Note: This description outlines duties and is not exhaustive. It is intended to reflect the general nature and level of work performed. EEO & Additional Information
Upward Health is an equal opportunity employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce.
#J-18808-Ljbffr
Company Overview:
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. We are driven by a desire to improve the lives of our patients across doctors, nurses, Care Specialists, HR, Technology, and Business Services staff. Our approach addresses a wide range of needs—from poorly controlled chronic conditions to anxiety to medically tailored meals—because health requires care for the whole person. Upward Health is proud to be an equal opportunity employer and values a diverse and inclusive workforce. Compensation:
Base pay range: $100,000.00/yr - $105,000.00/yr Job Title & Role Description
The
Nurse Care Manager
is responsible for telephonic care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team Pod, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on care transitions, particularly for patients discharged from inpatient settings, and involves 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. Responsibilities
Provide telephonic care coordination for high-risk patients; develop and monitor comprehensive care plans addressing chronic conditions; support care transitions and post-discharge follow-up; perform medication reconciliation; ensure continuity of care across providers, hospitals, and outpatient services; advocate for patients and coordinate services to improve outcomes. Qualifications & Skills
Expertise in care management and coordination across healthcare providers Strong communication skills for patient and caregiver education Ability to conduct telephonic assessments, care plans, and medication reconciliation 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 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. 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. Clinical Expertise: Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans. Effective Communication: Delivers 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 Orientation: Focused on achieving optimal clinical and financial outcomes through effective care coordination and management. Independent and Team-Oriented: Able to work independently in a remote environment while collaborating with a multidisciplinary team. Critical Thinking: Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed. Multitasking and Prioritization: Manages multiple patient cases and prioritizes tasks to meet deadlines and ensure comprehensive care. Employment Type & Industry
Employment type: Full-time Job function: Health Care Provider Industry: Hospitals and Health Care Note: This description outlines duties and is not exhaustive. It is intended to reflect the general nature and level of work performed. EEO & Additional Information
Upward Health is an equal opportunity employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce.
#J-18808-Ljbffr