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. 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 Senior Nurse Care Manager is a leadership role in a remote capacity, focused on providing high-level telephonic care coordination for high-risk patients with complex chronic conditions. This role goes beyond standard care management to include mentoring, guiding, and overseeing a team of Nurse Care Managers while ensuring that patients' care plans are tailored to their individual needs and that care transitions are executed smoothly. The Senior Nurse Care Manager will lead care coordination efforts for a diverse patient population, working closely with the multidisciplinary Care Team Pod to ensure that care plans are followed and that patients’ clinical and social needs are met effectively. This role requires advanced knowledge in care management and will act as an expert resource for less experienced staff.

The Senior Nurse Care Manager will also work with the management team to optimize workflows, identify opportunities for improvement, and implement best practices to ensure high-quality, cost-effective outcomes. The Senior Nurse Care Manager serves as the main point of contact for resolving escalated patient issues and will play a key role in ensuring that the organization's strategic care coordination goals are met.

Skills Required:

• Registered nursing license (unrestricted)
• Advanced expertise in care management and coordination across healthcare providers
• Strong communication and leadership skills for mentoring staff and educating patients and caregivers
• Ability to conduct telephonic assessments, care plans, and medication reconciliation with a focus on complex cases
• Extensive experience with EHR systems and real-time documentation
• Proven ability to work independently and manage a high volume of complex patient cases
• Critical thinking and decision-making skills to manage high-risk patients and oversee care plan development
• Proficiency in using digital tools for care coordination and interdepartmental communication
• Experience with care transitions, including leadership in post-discharge care management
• Ability to foster collaboration across teams and ensure continuity of care

Key Behaviors:

Leadership in Care Management:

• Provides mentorship, guidance, and support to other Nurse Care Managers, ensuring high standards of care coordination and patient outcomes.

Patient-Centered Care:

• Demonstrates advanced skills in developing trusting relationships with patients and caregivers, advocating for their needs and empowering them to follow care plans.

Collaboration & Team Leadership:

• Leads by example in collaborating effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.

Proactive Communication & Escalation Management:

• Effectively communicates with patients, caregivers, and interdisciplinary teams to resolve issues and ensure smooth care transitions. Handles escalated patient concerns with expertise.

Advanced Problem-Solving:

• Identifies systemic gaps in care and works across teams to implement solutions that improve patient care outcomes.

Care Coordination Excellence:

• Ensures coordination of care is managed effectively, particularly during transitions of care from inpatient to home care.

Time Management & Prioritization:

• Manages a caseload of complex patients while providing oversight and support to the broader care team, ensuring that tasks are completed promptly and efficiently.

Quality Assurance & Continuous Improvement:

• Actively participates in quality improvement initiatives, optimizing care delivery processes and workflows to improve patient outcomes and reduce costs.

Confidentiality & Compliance:

• Strictly adheres to HIPAA regulations and privacy laws, maintaining confidentiality in all patient-related matters.

Cultural Competence:

• Demonstrates respect for cultural diversity, ensuring care is tailored to meet the unique needs of diverse patient populations.

Competencies:

Advanced Clinical Expertise:

• Deep knowledge of chronic disease management, care transitions, evidence-based practices, and advanced care planning for complex cases.

Leadership & Mentorship:

• Strong ability to guide, support, and develop Nurse Care Managers and other team members to promote professional growth and improve patient care.

Effective Communication & Conflict Resolution:

• Skilled at communicating complex information to patients, caregivers, and interdisciplinary teams, and resolving conflicts or challenges effectively.

Care Plan Development & Oversight:

Proficient in creating, reviewing, and refining personalized care plans that address the full range of physical, behavioral, and social health needs.

Technology & Data Proficiency:

• Advanced ability to use electronic health records (EHR) and other digital tools to document, track, and manage patient care effectively.

Outcome-Oriented Leadership:

• Focused on achieving high-quality clinical and financial outcomes for patients through effective care management and leadership.

Critical Thinking & Decision-Making:

• Uses advanced clinical judgment to assess, analyze, and modify care plans, managing complex patient cases and ensuring optimal outcomes.

Multitasking & Workflow Optimization:

• Skilled at balancing multiple patient cases, leading a team, and optimizing workflows to improve care delivery efficiency.

Patient Engagement & Empowerment:

• Demonstrates leadership in motivating patients to follow care plans and enhance self-management through clear 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.