RN Nurse Care Manager

The RN Nurse Care Manager position at HarmonyCares supports in-home primary care for patients with complex healthcare needs in Reading, Pennsylvania. HarmonyCares delivers value-based services through a team-based, physician-driven model across multiple states, with this role focused on high-risk patient caseloads. The schedule follows daytime orientation and training hours with no holidays or weekends required.

Responsibilities

• Coordinates care services with the pod leader to ensure patients access a comprehensive set of services tailored to their needs
• Develops and manages personalized care plans with the care team, addresses care gaps, and engages resources to ensure access to care
• Coordinates patient transitions across the care continuum to meet needs and prevent avoidable hospital admissions
• Coordinates and facilitates High Risk Huddles and ensures follow-up actions are completed
• Prioritizes patients based on condition severity and urgency
• Reviews medical records to identify gaps in care and coordinates services with the care team
• Regularly updates patient care plans
• Performs nursing assessments via telephone to maximize or improve health outcomes
• Provides education to patients and caregivers on disease management, medication, health maintenance, and prevention
• Documents interactions, assessments, and updates in patient medical records per processes and guidelines
• Serves as liaison between patients, providers, and resources to ensure seamless care delivery
• Facilitates communication of patient status and plan of care during transitions such as home to hospital or hospital to post-acute care

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 computer programs including email, Word, Excel, and PowerPoint
• Ability to manage time effectively to complete all duties and documentation requirements

Benefits

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