Nurse Care Coordinator

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 Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and 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.

Skills Required :

• Registered nursing license (unrestricted)
• Expertise in care management and coordination across healthcare providers
• Strong communication skills for patient and caregiver education
• Ability to conduct both in-home and telephonic assessments, care plans, and medication reconciliations
• 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
• A valid driver's license and auto liability insurance
• Reliable transportation and the ability to travel within assigned territory or as needed
• Case management certification is a plus but not required

Key Behaviors :

Patient-Centered Care :

Collaboration :

Proactive Communication :

Advocacy and Education :

Care Coordination :

Time Management :

Problem Solving :

Confidentiality :

Cultural Competence :

Competencies : Clinical Expertise :

Effective Communication :

Care Plan Development :

Technology Proficiency :

Outcome-Oriented :

Independent and Team-Oriented :

Critical Thinking :

Multitasking and Prioritization :

Patient Engagement :

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.