Job Description

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 responsible for comprehensive care coordination for high-risk patients in Contra Costa County. This role focuses on care planning, emergency department (ED) avoidance, and discharge planning for patients transitioning between levels of care. The Nurse Care Manager will work closely with patients, caregivers, health plans, and primary care providers to facilitate seamless care across settings and ensure continuity of services.

This is a remote position with the autonomy to visit patients in their homes or at the hospital, as clinically appropriate. Additionally, the Nurse Care Manager will lead interdisciplinary team (IDT) meetings with a clinical focus to align care plans and support patient-centered outcomes.

Skills Required:

• Active, unrestricted Registered Nursing (RN) license in California

• Minimum of 3-5 years of case management experience, including care planning and coordination

• Strong knowledge of POLST, Advance Directives, and end-of-life planning

• Experience with home health, hospice, and care transitions

• Proficiency in electronic health record (EHR) systems and digital care management tools

• Excellent communication and patient education skills

• Critical thinking and decision-making abilities in complex care management

• Ability to work independently

• Experience collaborating with health plans, PCPs, and community resources

Key Behaviors:

Patient-Centered Care:

• Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow care plans.

Collaboration:

• Effectively coordinates care with the patient’s health plan, primary care provider, and other care team members to optimize health outcomes.

Proactive Communication:

• Actively engages patients and caregivers within 48 hours of hospital discharge to assess needs, update care plans, and mitigate potential readmission risks.

Advocacy and Education:

• Provides clear, compassionate education to patients and families regarding POLST, Advance Directives, and available support services.

Care Coordination:

• Ensures that care is effectively coordinated across multiple providers and services, particularly during transitions of care.

Time Management:

• Efficiently manages patient caseloads, balancing multiple tasks while adhering to established deadlines and care plans.

Problem Solving:

• Identifies potential gaps in care, collaborates with providers to resolve issues, and implements strategies to optimize patient outcomes.

Confidentiality:

• Maintains patient confidentiality and follows HIPAA regulations in all communications and documentation.

Cultural Competence:

• Demonstrates respect for diversity, providing culturally sensitive care that meets the needs of diverse patient populations.

Competencies:

Clinical Expertise:

• Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.

Effective Communication:

• Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.

Care Plan Development:

• Proficient in creating personalized care plans that address physical, behavioral, and social health needs.

Technology Proficiency:

• Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.

Outcome-Oriented:

• Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.

Independent and Team-Oriented:

• Able to work independently in a remote environment while also collaborating effectively with a multidisciplinary team.

Critical Thinking:

• Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.

Multitasking and Prioritization:

• Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.

Patient Engagement:

• Motivates patients to follow care plans and improve self-care skills through regular 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.

Compensation details: 100000-105000 Yearly Salary

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