Job Details

Nurse Care Manager

  2023-09-13     HarmonyCares     Roanoke,VA  


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 Through Compassionate Patient-Centered Care in the Home; We will Provide Exceptional Outcomes across our Continuum of Services

Our Values Respect, Integrity, Teamwork and Excellence - are leading us to a better tomorrow for patient care.

Why You Should Want to Work with Us

  • Quarterly Bonuses up to $5000 per year!
  • 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!

A Nurse Care Manager works closely with HarmonyCares Primary Care (HCPC) in home health care continuum and specialty services to maximize the health of the HCPC patients. This position requires home visits to the high risk patients and their caregivers to perform assessments, serve as an advocate to identify life goals, provide input in the treatment planning process and offer solutions to improve patient care. The Nurse Care Manager will also ensure the coordination and communication of a patient s treatment plan and general status to all providers and care givers during the continuum of care. This position requires advanced nursing knowledge and expertise to identify gaps in care, provide education, assist with resources, partner with continuum to reduce unplanned hospitalizations and ensure the right care at the right time.

Essential Duties & Responsibilities

  • Provides on-site clinical coordination
  • 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
  • Coordinates the transition of care for patients throughout the continuum to ensure patient needs are met accordingly via case conferencing with providers and continuum partners
  • Collaborates with all continuum partners (providers, HCPC/Hospice/Home Health staff, patients/families, community agencies, clinical liaisons)
  • Serves as an educational resource regarding home care for providers, patients, and care givers
  • Perform basic nursing assessment of patients (with their input) to maximize or improve current health status and independence to assist with avoiding unnecessary hospitalization or emergency visits to include but not limited to: urine analysis, blood sugar testing as needed based on patient care
  • Review of medical records to identify gaps in care and coordinate services with the care team to manage these issues
  • Educate the patient and the care giver on the importance of care in the continuum; this will enable providers to communicate with each other, identifying gaps in care, reduce hospital readmission, improved outcomes and patient satisfaction
  • When necessary or as directed, travel to patient locations such as hospital, skilled nursing facility, an in the home to assess patient needs and status
  • Facilitate 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
  • Communicate with the providers, patient or care giver, and any specialty program staff that are available, such as hospice, and homecare
    • Works closely with all providers to include Physicians, Nurse Practitioners (NP), Physician Assistants-(PA) regarding:
    • Criteria for home care referrals
    • Case conferencing to coordinate care, improve documentation and communication
  • Assists with documentation to support eligibility of patient under the care of hospice or home care (which may include chart audit worksheet, Labs, diagnostics, History and Physical, Fast Scale, Mortality Risk Scale, etc.*)
  • Provides periodic ride-along with physician Providers (Physicians, NP/PA s)
  • Identifies any potential opportunities for improvements within the program/continuum or any needed program development
  • Complete and submit reports and data on a daily, weekly, and monthly basis to track volume and productivity

Required Knowledge, Skills and Experience

  • Active R.N. License
  • Active CPR Certificate
  • 2 or more years of direct home health experience or care management
  • Must maintain a valid driver s license and good driving record
  • Ability to perform extensive telephone assessment
  • Knowledge of Medicare regulations and home care and hospice standards
  • Experience with small group presentations and teaching/training
  • Understanding of adult learning principles

Preferred Knowledge, Skills and Experience

  • Bachelor of Science
  • 1 year experience of discharge planning
  • 1 year leadership and/or supervisory experience
Pay Transparency: Individual compensation packages are based on various factors unique to each candidate, including skill set, experience, qualifications, and other job-related considerations.

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