RN Nurse Care Manager

The RN Nurse Care Manager role at HarmonyCares supports in-home primary care delivery for patients with complex healthcare needs. HarmonyCares operates a value-based, home-based primary care practice across 14 states from its Troy, Michigan headquarters, and this position is based in Flint, Michigan. The role manages a caseload of high-risk patients as co-chair of the care pod alongside the pod leader under a team-based, physician-driven model.

Responsibilities

• Coordinate care services with the pod leader to deliver a full range of services matched to individual patient needs across the healthcare continuum
• Collaborate with the care team on personalized care plan development, care gap identification, and resource engagement
• Manage patient transitions across settings to meet needs and prevent avoidable hospital admissions
• Lead high-risk patient huddles and complete all required follow-up actions
• Assign priority to patients according to condition severity and urgency
• Review medical records to detect care gaps and arrange services with the care team
• Maintain and update patient care plans on a regular schedule
• Conduct detailed nursing assessments by telephone to support improved health outcomes
• Deliver education on disease processes, medications, health maintenance, and prevention to patients and caregivers
• Record all interactions, assessments, and plan updates in patient medical records following established processes
• Act as liaison among patients, providers, and resources to support continuous care delivery
• Communicate patient status and care plans during transitions such as home to hospital or hospital to post-acute settings

Requirements

• Active Registered Nurse License
• 2+ years of care management experience in community, health plan, or hospital systems
• Ability to perform extensive telephone assessments
• Knowledge of Medicare regulations and home care and hospice standards
• Experience with small group presentations and teaching or training
• Working knowledge of email, word processing, spreadsheet, and presentation software
• Bachelor of Science in Nursing or related field (preferred)
• Ability to obtain multi-state licensing if required (preferred)
• Knowledge of population health, quality measures, care gap closure, and value-based care models (preferred)

Benefits

• Quarterly bonuses
• Health, dental, vision, disability, and life insurance
• 401(k) retirement plan with company match
• Tuition, professional license, and certification reimbursement
• Paid time off, holidays, and paid volunteer time
• Daytime orientation and training hours with no holidays or weekends required